- An insurer shall establish and maintain a formal internal appeals process whereby a member or member representative who is dissatisfied with a decision rendered in the informal appeals process can have the opportunity to pursue an appeal before a reviewer or panel of physicians, or advanced practice registered nurses, or other health care professionals selected by the insurer.
- (1) The reviewer or panel selected by the insurer pursuant to subsection (a) of this section shall not have been involved in the grievance decision under review.
- For all reviews requiring medical expertise, the reviewer or panel shall include at least one medical reviewer who is trained or certified in the same specialty as the matter at issue.
- A medical reviewer shall be a physician, or an advance practice registered nurse or other appropriate health care provider possessing a nonrestricted license to practice or provide care anywhere in the United States and have no history of disciplinary action or sanctions pending or taken against them by any governmental or professional regulatory body.
- A medical reviewer shall be certified by a recognized specialty board in the areas appropriate to review.
- All formal internal appeals shall be acknowledged by the insurer, in writing, to the member or member representative filing the appeal within 10 business days of receipt.
- All formal internal appeals shall be concluded as soon as possible after receipt by the insurer of all necessary documentation in accordance with the medical exigencies of the case. If the formal internal appeal is from a decision regarding urgent or emergency care, the insurer shall conclude the appeal within 24 hours notification of appeal by the member or member representative. All other appeals conducted pursuant to this section shall be concluded by the insurer within 30 business days; except, that the time may be extended at the request of a member or the member representative.
- If an insurer denies a member's or member representative's formal internal appeal, the insurer shall provide the member or member representative with a written explanation of the denial and written notification of his or her right to proceed to an external appeal. This notification shall include specific instructions as to how the member or member representative may arrange for an external appeal and shall also include any forms required to initiate the external appeal.
- At a minimum, the written explanation provided by the insurer of the determination pursuant to subsection (e) of this section shall include the following:
- The reviewer's understanding of the member's or member representative's complaint;
- The reviewer's decision in clear terms;
- The contractual basis or medical rationale in enough detail for the member or member representative to understand and to respond to the insurer's position; and
- All applicable instructions, including the telephone numbers and titles of persons to contact and time frames to appeal the decision to the next stage of appeal.
- In the event that the insurer fails to comply with any of the deadlines for completion of a formal internal appeal, the member or member representative shall be relieved of his or her obligation to complete the formal internal review process and may, at his or her option, proceed directly to the external appeals process required by § 44-301.07.
Historical and Statutory
1981 Ed., § 32-571.6.
Legislative History of Laws
For legislative history of D.C. Law 12-274, see Historical and Statutory Notes following § 44-301.01.
DC CODE § 44-301.06
Current through December 11, 2012
(Apr. 27, 1999, D.C. Law 12-274, § 106, 46 DCR 1294.)