A.R.S. tit. 20 ch. 15 — Arizona Revised Statutes Title 20 Chapter 15 — Utilization Review

20-2501. Definitions; scope A. In this chapter, unless the context otherwise requires: 1. "Adverse determination": (a) Means a utilization review determination by the utilization review agent that a requested service or claim for service or a denial, reduction or termination of a service, in whole or in part, is not a covered service, or is not medically necessary or appropriate, including health care setting, level of care or effectiveness of a covered benefit, or is experimental or investigational under the plan if that determination results in a documented denial or nonpayment of the service or claim. (b) Includes a rescission. 2. "Benefits based on the health status of the insured" means a contract of insurance to pay a fixed benefit amount, without regard to the specific services received, to a policyholder who meets certain eligibility criteria based on health status including: (a) A disability income insurance policy that pays a fixed daily, weekly or monthly benefit amount to an insured who is deemed to have a disability as defined by the policy terms. (b) A hospital indemnity policy that pays a fixed daily benefit during hospital confinement. (c) A disability insurance policy that pays a fixed daily, weekly or monthly benefit amount to an insured who is certified by a licensed health care professional as chronically ill as defined by the policy terms. (d) A disability insurance policy that pays a fixed daily, weekly or monthly benefit amount to an insured who suffers from a prolonged physical illness, disability or cognitive disorder as defined by the policy terms. 3. "Claim": (a) Means a request for payment for a service already provided. (b) Does not include: (i) Claim adjustments for usual and customary charges for a service or coordination of benefits between health care insurers. (ii) A request for payment under a policy or contract that pays benefits based on the health status of the insured and that does not reimburse the cost of or provide covered services. 4. "Covered service" means a service that is included in a policy, evidence of coverage or similar document that specifies which services, insurance or other benefits are included or covered. 5. "Denial": (a) Means a direct or indirect determination regarding all or part of a request for any service. (b) Includes a denial, reduction or termination of a service or a rescission or a direct determination regarding a claim that may trigger a request for review. (c) Does not include: (i) Enforcement of a health care insurer's deductibles, copayments or coinsurance requirements or adjustments for usual and customary charges, deductibles, copayments or coinsurance requirements for a service or coordination of benefits between health care insurers. (ii) The rejection of a request for payment under a policy or contract that pays benefits based on the health status of the insured and that does not reimburse the cost of or provide covered services. 6. "Final internal adverse determination" means an adverse determination that is upheld, in whole or in part, at the completion of the health care insurer's internal levels of review or an adverse determination with respect to which the internal levels of review have been waived or deemed exhausted. 7. "Grandfathered individual plan" means coverage provided by an individual health care insurer which was purchased before March 23, 2010 and which has not lost such status due to changes in benefits. 8. "Health care insurer" means a disability insurer, group disability insurer, blanket disability insurer, health care services organization, hospital service corporation, prepaid dental plan organization, medical service corporation, dental service corporation or optometric service corporation or a hospital, medical, dental and optometric service corporation. 9. "Health care setting" means an institution providing health care services, including but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers and rehabilitation and other therapeutic health settings. 10. "Indirect denial" means a failure to communicate authorization or nonauthorization to the member by the utilization review agent within the prescribed time frames pursuant to section 20-3404 after the utilization review agent receives the request for a covered service. 11. "Internal levels of review" means: (a) An expedited medical review and expedited appeal pursuant to section 20-2534. (b) An initial internal appeal pursuant to section 20-2535. (c) A voluntary internal appeal pursuant to section 20-2536, if applicable. 12. "Provider" means the physician or other licensed practitioner identified to the utilization review agent as having primary responsibility for providing care, treatment and services rendered to a patient. 13. "Rescission" means a retroactive cancellation of coverage that is not related to a failure to timely pay required premiums. 14. "Service" means a diagnostic or therapeutic medical or health care service, benefit or treatment. 15. "Utilization review" means a system for reviewing the appropriate and efficient allocation of inpatient hospital resources, inpatient medical services and outpatient surgery services that are being given or are proposed to be given to a patient, and of any medical, surgical and health care services or claims for services that may be covered by a health care insurer depending on determinable contingencies, including without limitation outpatient services, in-office consultations with medical specialists, specialized diagnostic testing, mental health services, emergency care and inpatient and outpatient hospital services. Utilization review does not include elective requests for the clarification of coverage. 16. "Utilization review agent" means a person or entity that performs utilization review. For purposes of article 2 of this chapter, utilization review agent has the same meaning prescribed in section 20-2530. For purposes of this chapter, utilization review agent does not include: (a) A governmental agency. (b) An agent that acts on behalf of the governmental agency. (c) An employee of a utilization review agent. 17. "Utilization review plan" means a summary description of the utilization review guidelines, protocols, procedures and written standards and criteria of a utilization review agent. B. For the purposes of this chapter, utilization review by an optometric service corporation applies only to nonsurgical medical and health care services. 20-2502. Utilization review activities; exemptions A. A utilization review agent shall not conduct utilization review in this state unless the utilization review agent meets or is exempt from this article. B. A person is exempt from sections 20-2504, 20-2505, 20-2506, 20-2507 and 20-2508 and section 20-2509, subsection A if the person: 1. Is accredited by the utilization review accreditation commission, the national committee for quality assurance or any other nationally recognized accreditation process recognized by the director. 2. Conducts internal utilization review for hospitals, home health agencies, clinics, private offices or other health facilities or entities if the review does not result in the approval or denial of payment for hospital or medical services. 3. Conducts utilization review activities exclusively for work related injuries and illnesses covered under the workers' compensation laws in title 23. 4. Conducts utilization review activities exclusively for a self-funded or self-insured employee benefit plan if the regulation of that plan is preempted by section 514(b) of the employee retirement income security act of 1974 (29 United States Code section 1144(b)). C. A utilization review agent shall conduct utilization review in accordance with the agent's utilization review plan that is on file with the department pursuant to section 20-2505 and in accordance with section 20-2532. 20-2503. Utilization review standards; applicability; definition A. The utilization review standards established in this chapter apply to prospective, concurrent and retrospective utilization review for: 1. Inpatient admissions to hospitals and other inpatient facilities. 2. Outpatient admissions to surgical facilities. 3. Outpatient surgical services provided in a health care provider's office. 4. Medical, surgical and health care services that may be covered by a health care insurer depending on determinable contingencies, including without limitation outpatient services, in-office consultations with medical specialists, specialized diagnostic testing, mental health services, emergency care and inpatient and outpatient hospital services. B. For purposes of this section "inpatient admissions" includes inpatient admissions to all acute medical, surgical, obstetrical, psychiatric and chemical dependency inpatient services at a licensed hospital or other inpatient facility. 20-2504. Utilization review agents; certification; rules A. The director shall issue a certificate to a utilization review agent that meets all of the requirements of this chapter and all applicable rules. A utilization review agent shall submit a signed and notarized application on a form prescribed by the director. B. A certificate is not transferable. C. The director may adopt rules consistent with the requirements of this chapter. D. Except as provided in section 20-2532, information required by the department with respect to customers, patients or utilization review plans is confidential and is not open to public inspection. E. The utilization review agent shall pay all certification expenses as provided in section 20-2506. 20-2505. Application for certification A utilization review agent applying for a certificate shall submit the following information to the department: 1. A signed and notarized application on a form prescribed by the director. 2. A utilization review plan that includes a summary description of review guidelines, protocols and procedures, standards and criteria to be used in evaluating inpatient hospital care, inpatient medical care, outpatient surgical care and any medical, surgical and health care services that may be covered by a health care insurer and the provisions by which patients, providers or hospitals may seek reconsideration or appeal of decisions made by the utilization review agent. 3. The professional qualifications of the personnel either employed or under contract to perform the utilization review. Personnel conducting utilization review shall have current licenses that are in good standing and without restrictions from a state health care professional licensing agency in the United States and may be a member of a profession that practices inpatient hospital or outpatient surgical care. 4. A description of the policies and procedures that ensure that a representative of the utilization review agent is available to receive and send the notice and acknowledgments prescribed in article 2 of this chapter and is reasonably accessible to patients and providers in this state and the department by a toll free telephone line or by acceptance of long-distance collect calls for forty hours each week during normal business hours. 5. A description of the policies and procedures that ensure that the utilization review agent will follow applicable state and federal laws to protect the confidentiality of individual medical records. 6. A copy of the materials or a description of the procedure designed to inform patients and providers, as appropriate, of the requirements of the utilization review plan. 20-2506. Certification; responsibilities of department; cost recovery A. The director shall examine the affairs, transactions, accounts and records of each utilization review agent before issuing an initial certificate and as often as the director deems it necessary in order to determine if a utilization review agent is in compliance with this chapter. The department shall not make any determination of quality of care, appropriateness of utilization review recommendations or medical necessity relating to any plan of care or treatment. B. All examination and examination related expenses shall be charged to the utilization review agent and shall be paid by the director out of the insurance examiners' revolving fund in accordance with section 20-159. C. The director may use independent contract examiners pursuant to sections 20-148 and 20-149 to perform the examinations under this section. D. Any expenses of examinations not paid by the utilization review agent within thirty days of the billing of the examination expenses shall be paid by the health care insurer that used the services or that contracted with the utilization review agent. If more than one health care insurer used the services of or contracted with a utilization review agent each health care insurer shall pay an equal share of the uncollected expenses. 20-2507. Certificates; renewal A. A certificate expires on the third anniversary of its effective date unless the certificate is renewed for a three year term as provided in this section. B. A certificate holder may renew an unexpired certificate for an additional three year term if the certificate holder meets the requirements of this chapter. 20-2508. Denial, suspension or revocation of certificates; hearing; civil penalties A. The director shall deny a certificate if the director finds that the utilization review agent does not: 1. Have an allopathic or osteopathic physician available to supervise utilization review activities of any medical, surgical or health care services except that: (a) A dental service corporation that is licensed pursuant to chapter 4, article 3 of this title and a prepaid dental plan organization that is licensed pursuant to chapter 4, article 7 of this title may have a licensed dentist supervise or conduct utilization review activities for health care services that involve dental care. (b) An optometric service corporation that is licensed pursuant to chapter 4, article 3 of this title may have a licensed optometrist supervise or conduct utilization review activities for health care services that involve optometric care. (c) A utilization review agent shall have a licensed chiropractor supervise or conduct utilization review activities for health care services that are performed by a chiropractor and within the chiropractor's scope of practice pursuant to title 32, chapter 8. 2. Meet all applicable department rules relating to the qualifications of utilization review agents or the performance of utilization review. 3. Provide assurances satisfactory to the director that the procedure and policies of the utilization review agent will protect the confidentiality of medical records and the utilization review agent will be reasonably accessible to patients and providers in this state and the department by a toll free telephone line or by acceptance of long-distance collect calls for forty hours each week during normal business hours. B. The director shall deny a certificate to a utilization review agent who has been convicted of a misdemeanor involving moral turpitude or a felony or who employs a person who has been convicted of a felony. C. The director may suspend, revoke or refuse to renew a certificate issued under this chapter if after giving notice to the utilization review agent, and holding a hearing if demanded by the agent, the director finds that the agent has violated this chapter or a rule adopted under this chapter. D. If after a hearing the director finds that the agent has violated this chapter or an applicable rule or order adopted under this chapter, the director shall issue an order that specifies the violation and may impose a civil penalty of not more than two hundred fifty dollars for each violation or an aggregate civil penalty of not more than two thousand five hundred dollars. The director may also impose a civil penalty of not more than two thousand five hundred dollars for each knowing violation or an aggregate civil penalty of not more than fifteen thousand dollars. The director shall deposit, pursuant to sections 35-146 and 35-147, all monies in the state general fund. A civil penalty is in addition to any other applicable penalty or restraint provided in this chapter and may be recovered in a civil action brought by the director. E. A certificate does not expire or terminate until a pending department investigation is resolved but is suspended on the date it would otherwise expire or terminate. The utilization review agent shall not transact business in this state until the investigation is completed. F. When the director suspends or revokes a certificate the director shall immediately notify the utilization review agent either by personal service or by mail addressed to the agent at the agent's address of record. Notice by mail is effective at the time it is mailed. G. The utilization review agent shall deliver a revoked or suspended certificate to the director on the director's request. H. The director shall not issue a new certificate earlier than one year after the date of a previous revocation. Agents shall reapply to the director and shall meet all the requirements of this chapter to obtain a new certificate. I. If the certificate of a firm or corporation is suspended or revoked, no member of that firm or officer or director of the corporation may hold a certificate during the period of the suspension or revocation unless the director determines, based on substantial evidence, that the member, officer or corporation director was not personally at fault. 20-2509. Confidentiality A. A utilization review agent shall file with the director written procedures for assuring that patient information it obtains during the process of utilization review is maintained as confidential in accordance with applicable federal and state laws, is used solely for the purposes of utilization review, quality assurance, discharge planning and catastrophic case management and is shared only with agencies authorized by the patient in writing and on a form prescribed by the director to receive the information. Summary data are not confidential if the data do not provide sufficient information to allow identification of individual patients. This subsection does not permit a person to obtain information without complying with other requirements of this title. B. A utilization review agent shall comply with all applicable state and federal laws relating to the confidentiality of medical records. 20-2510. Health care insurers requirements; medical directors A. A health care insurer that proposes to provide coverage of inpatient hospital and medical benefits, outpatient surgical benefits or any medical, surgical or health care service for residents of this state with utilization review of those benefits shall meet at least one of the following requirements: 1. Have a certificate issued pursuant to this chapter. 2. Be accredited by the utilization review accreditation commission, the national committee for quality assurance or any other nationally recognized accreditation process recognized by the director. 3. Contract with a utilization review agent that has a certificate issued pursuant to this chapter. 4. Contract with a utilization review agent that is accredited by the utilization review accreditation commission, the national committee for quality assurance or any other nationally recognized accreditation process recognized by the director. 5. Provide to the director a signed and notarized statement that the health care insurer has submitted an application for accreditation to the utilization review accreditation commission or the national committee for quality assurance and is awaiting completion of the accreditation review process. On completion of the accreditation review process, the insurer shall provide to the director adequate proof that the insurer has been accredited. If the insurer is denied accreditation, within sixty days after the denial the insurer shall meet at least one of the requirements set forth in paragraph 1, 2, 3 or 4 of this subsection. B. Except as provided in subsections C, D and E of this section, any direct denial of prior authorization of a service requested by a health care provider on the basis of medical necessity by a health care insurer shall be made in writing by a medical director who holds an active unrestricted license to practice medicine in this state pursuant to title 32, chapter 13 or 17. The written denial shall include an explanation of why the treatment was denied. The health care insurer shall send a copy of the written denial to the health care provider who requested the treatment. Health care insurers shall maintain copies of all written denials and shall make the copies available to the department for inspection during regular business hours. The medical director is responsible for all direct denials that are made on the basis of medical necessity. Nothing in this section prohibits a health care insurer from consulting with a licensed physician whose scope of practice may provide the health care insurer with a more thorough review of the medical necessity. C. For determinations made pursuant to subsection B of this section, a dental service corporation as defined in section 20-822 or a prepaid dental plan organization as defined in section 20-1001 may use as a medical director either: 1. An individual who holds an active unrestricted license to practice dentistry in this state pursuant to title 32, chapter 11. 2. A physician who holds an active unrestricted license to practice medicine in this state pursuant to title 32, chapter 13 or 17. D. For determinations made pursuant to subsection B of this section, an optometric service corporation may use as a medical director either: 1. An individual who holds an active unrestricted license to practice optometry in this state pursuant to title 32, chapter 16. 2. A physician who holds an active unrestricted license to practice medicine in this state pursuant to title 32, chapter 13 or 17. E. For determinations made pursuant to subsection B of this section, a health care insurer shall use a chiropractor licensed in this state pursuant to title 32, chapter 8 or by any regulatory board in another state to review any direct denial of prior authorization of a chiropractic service requested by a chiropractor on the basis of medical necessity. 20-2511. Violation; injunctive relief If the director believes that a utilization review agent is violating or is about to violate section 20-2502, the director may order the agent to cease and desist. The director through the attorney general may file a complaint in the superior court in the county in which the agent transacts utilization review business to enjoin and restrain the agent from committing or continuing the violation. If the director orders the utilization review agent to cease and desist, the agent may request a hearing pursuant to title 41, chapter 6, article 10 and, except as provided in section 41-1092.08, subsection H, seek judicial review pursuant to title 12, chapter 7, article 6. If the director files a complaint through the attorney general the superior court has jurisdiction of the proceeding and may make and enter an order or judgment awarding preliminary or final relief as in its judgment is proper. 20-2530. Definitions For the purposes of this article: 1. "Member" means a person who is covered under a health care plan provided by a health care insurer or that person's treating provider, parent, legal guardian, surrogate who is authorized to make health care decisions for that person by a power of attorney, a court order or the provisions of section 36-3231, or agent who is an adult and who has the authority to make health care treatment decisions for that person pursuant to a health care power of attorney. 2. "Utilization review agent" means those persons and entities that perform utilization review as defined in section 20-2501 and includes any health care insurer whose utilization review plan includes the direct or indirect denial of requested medical or health care services or the denial of claims. 20-2531. Applicability; requirements; exception A. Notwithstanding article 1 of this chapter and subject to subsection B of this section, this article applies to all utilization review decisions made by utilization review agents and health care insurers operating in this state. B. Each utilization review agent and each health care insurer operating in this state whose utilization review system includes the power to affect the direct or indirect denial of requested medical or health care services or claims for medical or health care services shall adopt written utilization review standards and criteria and processes for the review, reconsideration and appeal of denials that do all of the following: 1. Meet the requirements of this article. 2. Are consistent with chapter 1 of this title. 3. Comply with section 20-2505, paragraphs 2 through 6. C. This article does not apply to utilization review: 1. Performed under contract with the federal government for utilization review of patients eligible for all services under title XVIII of the social security act. 2. Performed by a self-insured or self-funded employee benefit plan or a multiemployer employee benefit plan created in accordance with and pursuant to 29 United States Code section 186(c) if the regulation of that plan is preempted by section 514(b) of the employee retirement income security act of 1974 (29 United States Code section 1144(b)), but this article does apply to a health care insurer that provides coverage for services as part of an employee benefit plan. 3. Of work related injuries and illnesses covered under the workers' compensation laws in title 23. 4. Performed under the terms of a policy that pays benefits based on the health status of the insured and does not reimburse the cost of or provide covered services. 5. Performed under the terms of a long-term care insurance policy as defined in section 20-1691. 6. Performed under the terms of a medicare supplement policy as defined by the department. D. This article does not create any new private right or cause of action for or on behalf of any member. This article provides only an administrative process for a member to pursue an external independent review of a denial for a covered service or claim for a covered service. E. Utilization review activities involving retrospective claims review are limited to the provisions of this article only as clearly and specifically provided in the provisions of this article. F. The processes available under this article do not apply to a denial of a nonformulary exception request that was appealed pursuant to 45 Code of Federal Regulations section 156.122(c). A provider or enrollee may appeal a denial of a nonformulary exception for a plan covered by 45 Code of Federal Regulations section 156.122(c) through the process prescribed in the federal rule. 20-2532. Utilization review standards and criteria; requirements A. Each utilization review agent shall: 1. Adopt a written utilization review plan with standards and criteria that apply to all utilization review determinations and that are objective, clinically valid and compatible with established principles of health care. 2. Establish the utilization review plan with input from physician advisors who represent major medical specialties and who are certified or board eligible under the standards of the appropriate American medical specialty board. 3. Include in the adopted utilization review plan a process for prompt initial reconsideration of an adverse determination and a process for appeals that meet the requirements of this article. This paragraph does not apply to utilization review activities limited to retrospective claims review. B. Deviations from the written standards and criteria in the utilization review plan are allowed if the utilization review agent determines that the member and other members with similar symptoms and diagnoses would materially benefit from new treatments available because of medical or technological advances made since the adoption of the utilization review plan and made in accordance with accepted medical standards. This subsection does not apply to utilization review activities limited to retrospective claims review. Nothing in this subsection creates a private right or cause of action against a health care insurer or utilization review agent for failure to deviate from the utilization review plan. C. A health care insurer who uses the services of an outside utilization review agent shall adopt a utilization review plan pursuant to subsections A and B of this section. The utilization review plan adopted and filed by the health care insurer who uses the services of an outside utilization review agent is deemed adopted by that utilization review agent. D. A health care insurer who uses the services of an outside utilization review agent is responsible for the utilization review agent's acts that are within the scope of the written and filed utilization review plan, including the administration of all patient claims processed by the utilization review agent on behalf of the health care insurer. E. Each utilization review agent shall file a notice with the director that provides a specific description and the published date of the source of the written standards and criteria of the utilization review plan and that certifies that the utilization review plan in use complies with the requirements of this section, is available for review and inspection at a designated location in this state or at an office accessible to authorized representatives of the director in another state and is the complete utilization review plan with all standards and criteria on which utilization review decisions are based. A copy of any portion of the utilization review plan on which any adverse determinations have been based shall be made before the effective date of any modification and the utilization review agent shall retain a copy at the designated location for review and inspection for a period of five years after the date of the modification. If at any time a complete change in the written standards and criteria occurs, the utilization review agent shall file a new certification notice with the director. F. On or before March 1 of each year after the year in which the utilization review agent filed the notice prescribed in subsection E of this section, the utilization review agent or the agent's successor shall submit a signed and notarized annual report to the director that includes the designated location for review and inspection by the director or the director's authorized representative and that certifies that: 1. The utilization review plan and all modifications remain in compliance with the requirements of this section. 2. The utilization review agent will conduct all utilization reviews in accordance with the plan. 3. All adverse determinations made in the prior year were based on the plan in effect on the date of those adverse determinations. G. On written request, the utilization review agent shall provide copies to any member or the member's treating provider of: 1. Those portions of the utilization review agent's utilization review plan that are relevant to the request for a covered service or claim for a covered service. 2. The protocols or guidelines that were used if the standards and criteria adopted are based on protocols or guidelines developed by an American medical specialty board. H. Any person who requests records pursuant to subsection G of this section shall direct the request to the utilization review agent and not to the department. I. If the utilization review plan is copyrighted by a person other than the utilization review agent, the health care insurer shall make a good faith effort to obtain permission from that person to make copies of the relevant material. If the health care insurer is unable to secure copyright permission, the utilization review agent shall provide a detailed summary of the relevant portions of the utilization review plan. J. Health care insurers having utilization review activities limited to retrospective claims review shall be required to adopt only those procedures and sources of review that are traditionally associated with and necessary for retrospective claims review. 20-2533. Denial; levels of review; disclosure; additional time after service by mail; review process A. No minimum dollar amount may be imposed on any claim that is the subject of an adverse determination for a member to, and any member who receives an adverse determination may, pursue the applicable review process prescribed in this article. Except as provided in sections 20-2534 and 20-2535, health care insurers shall provide at least the following levels of review, as applicable: 1. An expedited medical review and expedited appeal pursuant to section 20-2534. 2. An initial appeal pursuant to section 20-2535. 3. An external independent review pursuant to section 20-2537. B. For group plans, and for grandfathered individual plans, a health care insurer may elect to offer a voluntary internal appeal pursuant to section 20-2536 as an additional internal level of review after a determination of an initial appeal. C. For individual plans and group plans for which the health care insurer does not elect to offer a voluntary internal appeal as an internal level of review, the health care insurer shall: 1. With the exception of a denial of a claim for service that has already been provided, send the member a written determination within thirty days after the health care insurer receives the appeal request. 2. For a denial of a claim for service that has already been provided, send the member a written determination within sixty days after the health care insurer receives the appeal request. D. A health care insurer that elects to offer a voluntary internal appeal for the health care insurer's group plans shall: 1. With the exception of a denial of a claim for service that has already been provided, send the member a written determination within fifteen days after the health care insurer receives the initial appeal request and within fifteen days after the health care insurer receives the voluntary internal appeal request. 2. For a denial of a claim for a service that has already been provided, send the member its written determination within thirty days after the health care insurer receives the health care insurer receives the initial appeal request and within thirty days after the health care insurer receives the voluntary internal appeal request. E. A health care insurer shall provide a written determination as required by this section and include the basis, criteria used, clinical reasons and rationale for the determination. F. Except as provided in sections 20-2534 and 20-2537, a member shall be considered to have exhausted a health care insurer's internal levels of review if the health care insurer fails to comply with this article, except to the extent that the member requested or agreed to the delay, and the member may simultaneously initiate an expedited external independent review. G. Notwithstanding subsection A, paragraph 2 of this section, a health care insurer may waive the internal appeal process. H. At the time coverage is initiated, each health care insurer that operates in this state and whose utilization review system includes the power to affect the direct or indirect denial of requested medical or health care services or claims for medical or health care services shall include a separate information packet that is approved by the director with the member's policy, evidence of coverage or similar document. At the time coverage is renewed, each health care insurer shall include a separate statement with the member's policy, evidence of coverage or similar document that informs the member that the member can obtain a replacement packet that explains the appeal process by contacting a specific department and telephone number. A health care insurer shall also provide a copy of the information packet to the member or the member's treating provider on request and shall prominently display a copy of the approved information packet on its website. The information packet provided by the health care insurer shall include all of the following information: 1. A detailed description and explanation of each level of review prescribed in subsections A and B of this section and notice of the member's right to proceed to the next level of review if the prior review is unsuccessful. 2. An explanation of the procedures that the member must follow, including the applicable time periods, for each applicable level of review prescribed in subsections A, B, C and D of this section and an explanation of how the member may obtain the member's medical records pursuant to title 12, chapter 13, article 7.1. 3. The specific title and department of the person and the address, telephone number and fax number or email address of the person whom the member must notify at each applicable level of review prescribed in subsections A and B of this section in order to pursue that level of review. 4. The specific title and department of the person and the address, telephone number and fax number or email address of the person who will be responsible for processing that review. 5. A notice that if the member decides to pursue an appeal the member must provide the person who will be responsible for processing the appeal with any material justification or documentation for the appeal at the time that the member files the written appeal. 6. A description of the utilization review agent's and health care insurer's roles at each applicable level of review prescribed by subsections A, B, C and D of this section and an outline of the director's role during the external independent review process, if not already described in response to paragraph 1 of this subsection. 7. A notice that if the member participates in the process of review pursuant to this article the member waives any privilege of confidentiality of the member's medical records regarding any person who examined or will examine the member's medical records in connection with that review process for the medical condition under review. 8. A statement that the member is not responsible for the costs of any external independent review. 9. Standardized forms that are prescribed by the department and that a member may use to file and pursue an appeal. 10. The name and telephone number for the department of insurance and financial institutions consumer assistance office with a statement that the department of insurance and financial institutions consumer assistance office can assist consumers with questions about the health care appeals process. I. At the time of issuing a denial, the health care insurer shall notify the member of the right to appeal under this article. A health care insurer that issues an explanation of benefits document shall satisfy this obligation by prominently displaying in the document a statement about the right to appeal. A health care insurer that does not issue an explanation of benefits document shall satisfy this obligation through some other reasonable means to assure that the member is apprised of the right to appeal at the time of a denial. A reasonable means that includes giving the member's treating provider a form statement about the right to appeal shall require the treating provider to notify the member of the member's right to appeal. J. Any written notice, acknowledgment, request, determination or other written document that is sent by mail is deemed received by the person to whom the document is properly addressed on the fifth business day after mailing. K. The director shall require any member who files a complaint with the department relating to an adverse determination to pursue the review process prescribed in this article. This subsection does not limit the director's authority pursuant to chapter 1, article 2 of this title. L. If the member's complaint involves an issue of medical necessity or appropriateness, including health care setting, level of care or effectiveness of a covered benefit, or is experimental or investigational under the coverage document and not whether the claim or service is covered, the initial appeal process shall be performed as prescribed by section 20-2535 by a licensed health care professional. If the member's complaint involves an issue of medical necessity or appropriateness, including health care setting, level of care or effectiveness of a covered benefit, or is experimental or investigational under the coverage document and not whether the claim or service is covered, the expedited review or voluntary internal appeal shall be decided by a physician, provider or other health care professional as prescribed by section 20-2534 or 20-2536. Any external independent review shall be decided by a physician, provider or other health care professional as prescribed by section 20-2537. M. Before a health care insurer makes a final internal adverse determination that relies on new or additional evidence generated directly or indirectly by the health care insurer, the health care insurer shall provide the new or additional information to the member free of charge sufficiently in advance of the final adverse determination to allow the member a reasonable opportunity to respond within the applicable time frames for the health care insurer to provide the member with a written determination prescribed in subsections C and D of this section. N. Any person given access to a member's medical records or other medical information in connection with proceedings pursuant to this article shall maintain the confidentiality of the records or information in accordance with title 12, chapter 13, article 7.1. 20-2534. Expedited medical review; expedited appeal A. Except for a denial of a claim for service or a rescission of coverage, any member who receives an adverse determination may pursue an expedited medical review of that denial if the member's treating provider certifies in writing and provides supporting documentation to the utilization review agent that the time period for the initial appeal process prescribed in section 20-2535 and, if applicable, the voluntary internal appeal process prescribed in section 20-2536 are likely to cause a significant negative change in the member's medical condition at issue that is subject to the appeal. The treating provider's certification is not challengeable by the health care insurer. A health care insurer whose utilization review activities consist only of claims review for services already provided is not required to provide its members an expedited medical review or expedited appeal pursuant to this section. A health care insurer who conducts utilization review of claims in connection with services already provided is not required to provide its members an expedited medical review or expedited appeal of a claim related to a service already provided. B. On receipt of the certification and supporting documentation, the utilization review agent has seventy-two hours to make a determination and send to the member and the member's treating provider a notice of that determination, including the basis, criteria used, clinical reasons and rationale for that determination and any references to supporting documentation. If the member's complaint involves an issue of medical necessity or appropriateness, including health care setting, level of care or effectiveness of a covered benefit, or is experimental or investigational under the coverage document and not whether the service is covered, before making a determination, the agent shall consult with a physician or other health care professional who is licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an out-of-state provider, physician or other health care professional who is licensed in another state and who is not licensed in this state and who typically manages the medical condition under review. C. If the utilization review agent affirms the denial of the requested service, the agent shall telephonically provide and send to the member and the member's treating provider a notice of the adverse determination and of the member's option to immediately proceed to an expedited appeal pursuant to subsection E of this section. D. At any time during the expedited appeal process, the utilization review agent may request an expedited external independent review pursuant to section 20-2537. If the utilization review agent initiates an expedited external independent review, the utilization review agent does not have to comply with subsection E of this section. E. If the member chooses to proceed with an expedited appeal, the member's treating provider shall immediately submit a written appeal of the denial of the service to the utilization review agent and provide the utilization review agent with any additional material justification or documentation to support the member's request for the service. Within three business days after receiving the request for an expedited appeal, the utilization review agent shall provide notice of the expedited appeal determination as prescribed in this subsection. If the member's complaint involves an issue of medical necessity or appropriateness, including health care setting, level of care or effectiveness of a covered benefit, or is experimental or investigational under the coverage document and not whether the service is covered, the utilization review agent shall select a provider who shall review the appeal and render the determination based on the utilization review plan adopted by the utilization review agent. If the utilization review agent or provider denies the expedited appeal, the utilization review agent shall telephonically provide and send to the member and the member's treating provider a notice of the denial and of the member's option to immediately proceed to the external independent review prescribed in section 20-2537. For the purposes of this subsection: 1. "Advanced practice registered nurse" means any of the following as defined in section 32-1601: (a) A certified nurse midwife. (b) A certified registered nurse anesthetist. (c) A clinical nurse specialist. (d) A registered nurse practitioner. 2. "Provider" means either of the following: (a) A physician or other health care professional who is licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an advanced practice registered nurse who is licensed pursuant to title 32, chapter 15, who is qualified in a similar scope of practice as a physician or other health care professional licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an advanced practice registered nurse who is licensed pursuant to title 32, chapter 15 and who is employed or under contract with the utilization review agent. (b) An out-of-state physician or other health care professional who is licensed in another state and who is not licensed in this state, who is employed or under contract with the utilization review agent and who either is qualified in a similar scope of practice as a physician or other health care professional licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an advanced practice registered nurse who is licensed pursuant to title 32, chapter 15 or who typically manages the medical condition under appeal. F. If the utilization review agent, provider, physician or other health care professional concludes that the covered service should be provided, the health care insurer is bound by the utilization review agent's determination. 20-2535. Initial appeal A. Any member who receives an adverse determination and who does not qualify for an expedited medical review pursuant to section 20-2534 may request, either orally or in writing, an initial appeal of that denial by notifying the person described in section 20-2533, subsection H, paragraph 3. After the denial, the member has up to two years to request an initial appeal. B. The utilization review agent may request any pertinent medical records pursuant to title 12, chapter 13, article 7.1 that are necessary for the initial appeal. C. If the member's appeal involves an issue of medical necessity or appropriateness, including health care setting, level of care or effectiveness of a covered benefit, or is experimental or investigational under the coverage document and not whether the service is covered, the utilization review agent shall select a provider to review the appeal and render a determination based on the utilization review plan. For the purposes of this subsection: 1. "Advanced practice registered nurse" means any of the following as defined in section 32-1601: (a) A certified nurse midwife. (b) A certified registered nurse anesthetist. (c) A clinical nurse specialist. (d) A registered nurse practitioner. 2. "Provider" means either of the following: (a) A physician or other health care professional who is licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an advanced practice registered nurse who is licensed pursuant to title 32, chapter 15, who is qualified in a similar scope of practice as a physician or other health care professional licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an advanced practice registered nurse who is licensed pursuant to title 32, chapter 15 and who is employed or under contract with the utilization review agent. (b) An out-of-state physician or other health care professional who is licensed in another state and who is not licensed in this state, who is employed or under contract with the utilization review agent and who either is qualified in a similar scope of practice as a physician or other health care professional licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an advanced practice registered nurse who is licensed pursuant to title 32, chapter 15 or who typically manages the medical condition under appeal. D. Within the time frames prescribed in section 20-2533, subsections C and D, the utilization review agent shall send to the member and the member's treating provider a notice of the utilization review agent's determination and the basis, criteria used, clinical reasons and rationale for that determination. E. At any time during the initial appeal process, the utilization review agent may submit a request to the director to initiate an external independent review process pursuant to section 20-2537. At the same time that the utilization review agent submits the request to the director, the utilization review agent shall also render a written determination and shall send the written determination, including the basis, criteria used, clinical reasons and rationale for that determination and any references to supporting documentation, to the member, the member's treating provider and the director. F. If the utilization review agent does not submit a request to the director pursuant to subsection E of this section and at the conclusion of the initial appeal process the utilization review agent denies the covered service or the claim for the covered service, the utilization review agent shall provide the member and the treating provider with a written statement of the agent's decision and the basis, criteria used, clinical reasons and rationale for that determination, including any references to any supporting documentation. The determination shall include a notice of the option to proceed to the voluntary internal appeal process pursuant to section 20-2536 for a group health plan or grandfathered individual plan for which the health care insurer elected to have a voluntary internal appeal level of review or to an external independent review pursuant to section 20-2537 if the health care insurer has only one internal level of review. G. If the utilization review agent concludes that the covered service should be provided or the claim for a covered service should be paid, the health care insurer is bound by the utilization review agent's determination. 20-2536. Voluntary internal appeal A. For a group health plan, or a grandfathered individual plan, if a health care insurer elects to include as part of its internal review levels a voluntary internal appeal level after any applicable initial appeal pursuant to section 20-2535 and the utilization review agent denies the member's initial request, the member may appeal that adverse determination to the voluntary internal appeal level. The member shall send a written appeal to the utilization review agent within sixty days after receipt of the adverse determination. B. The member or the member's treating provider shall submit to the utilization review agent with the written voluntary internal appeal any material justification or documentation to support the member's request for the service or claim for a service. C. If the member's appeal involves an issue of medical necessity or appropriateness, including health care setting, level of care or effectiveness of a covered benefit, or is experimental or investigational under the coverage document and not whether the service is covered, the utilization review agent shall select a provider to review the appeal and render a determination based on the utilization review plan adopted by the utilization review agent. For the purposes of this subsection: 1. "Advanced practice registered nurse" means any of the following as defined in section 32-1601: (a) A certified nurse midwife. (b) A certified registered nurse anesthetist. (c) A clinical nurse specialist. (d) A registered nurse practitioner. 2. "Provider" means either of the following: (a) A physician or other health care professional who is licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an advanced practice registered nurse who is licensed pursuant to title 32, chapter 15, who is qualified in a similar scope of practice as a physician or other health care professional licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an advanced practice registered nurse who is licensed pursuant to title 32, chapter 15 and who is employed or under contract with the utilization review agent. (b) An out-of-state physician or other health care professional who is licensed in another state and who is not licensed in this state, who is employed or under contract with the utilization review agent and who either is qualified in a similar scope of practice as a physician or other health care professional Licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 or an advanced practice registered nurse who is licensed pursuant to title 32, chapter 15 or who typically manages the medical condition under appeal. D. Except as provided in subsection E of this section, the utilization review agent shall send to the member and the member's treating provider a notice of the utilization review agent's determination and the basis, criteria used, clinical reasons and rationale for that determination within the time frames prescribed in section 20-2533, subsection D. E. At any time during the voluntary internal appeal process, the utilization review agent may request an external independent review process pursuant to section 20-2537. If the utilization review agent initiates the external independent review process, the utilization review agent does not have to comply with subsection d of this section. F. If at the conclusion of the voluntary internal appeal process the utilization review agent denies the appeal and the utilization review agent does not initiate the external independent review process, the utilization review agent shall provide the member with notice of the option to proceed to an external independent review pursuant to section 20-2537. G. If the utilization review agent concludes that the covered service should be provided or the claim for a covered service should be paid, the health care insurer is bound by the utilization review agent's determination. 20-2537. External independent review; expedited external independent review (Conditionally Rpld.) A. If the utilization review agent denies the member's request for a covered service or claim for a covered service at all applicable internal levels of review or if the member has exhausted the health care insurer's internal levels of review pursuant to section 20-2533, subsection F, the member may initiate an external independent review. B. Except as provided in subsection N of this section, a member may initiate an external independent review within four months after the member receives written notice by the utilization review agent of an adverse determination made pursuant to section 20-2534 or 20-2536 by sending to the utilization review agent a written request for an external independent review, including any material justification or documentation to support the member's request for the covered service or claim for a covered service. C. Except as provided in subsection N of this section, within five business days after the utilization review agent receives a request for an external independent review from the member pursuant to subsection B of this section or the director pursuant to subsection J of this section, or if the utilization review agent initiates an external independent review pursuant to section 20-2536, subsection F, the utilization review agent shall: 1. Send a written acknowledgment to the director, the member, the member's treating provider and the health care insurer. The acknowledgement shall include notice to the member that the member has five business days after receiving the notice to submit additional written evidence to the department for consideration by the assigned independent review organization. 2. Forward to the director the request for review, the terms of agreement in the member's policy, evidence of coverage or a similar document and all medical records and supporting documentation used to render the determination pertaining to the member's case, a summary description of the applicable issues including a statement of the utilization review agent's determination, the basis, criteria used, clinical reasons and rationale for that determination, the relevant portions of the utilization review agent's utilization review plan and the name and credentials of the licensed health care provider who reviewed the case as required by section 20-2533, subsection L. D. Except as provided in subsection N of this section, within five days after the director receives all of the information prescribed in subsection C, paragraph 2 of this section and if the case involves an issue of medical necessity or appropriateness, including health care setting, level of care or effectiveness of a covered benefit, or is experimental or investigational under the coverage document, the director shall choose an independent review organization procured pursuant to section 20-2538 and forward to the organization all of the information required by subsection C, paragraph 2 of this section. E. Within one business day after the director receives additional written evidence submitted by the member