514J.5 - CERTIFICATION OF REQUEST -- ELIGIBILITY.
514J.5 CERTIFICATION OF REQUEST -- ELIGIBILITY. 1. The commissioner shall have two business days from receipt of a request for an external review to certify the request. The commissioner shall certify the request if all of the following criteria are satisfied: a. The enrollee was covered by the carrier or organized delivery system at the time the service or treatment was proposed or received. b. The enrollee has been denied coverage based on a determination by the carrier or organized delivery system that the proposed or received service or treatment does not meet the definition of medical necessity as defined in the carrier's or organized delivery system's plan or policy. c. The enrollee, or the enrollee's treating health care provider acting on behalf of the enrollee, has exhausted all internal appeal mechanisms provided under the carrier's or the organized delivery system's plan or policy. d. The written request for external review was filed within sixty days of receipt of the coverage decision. 2. The commissioner shall notify the enrollee, or the enrollee's treating health care provider acting on behalf of the enrollee, and the carrier or organized delivery system in writing of the certification. 3. The carrier or organized delivery system has three business days from the date of receipt to contest the commissioner's certification decision. If the commissioner finds that the request for external review is not eligible for certification, the commissioner, within two business days of the date of the request, shall notify the enrollee, or the enrollee's treating health care provider acting on behalf of the enrollee, in writing of the reasons that the request for external review is not eligible for certification. If the commissioner finds that the request for external review is eligible for certification, notwithstanding the contest by the carrier or organized delivery system, the commissioner shall promptly notify the carrier or organized delivery system in writing of the reasons for upholding the certification.
Section History: Recent Form 99 Acts, ch 41, §11, 22; 2001 Acts, ch 69, §26; 2002 Acts, ch 1119, §69 Referred to in § 514J.7