Section 420-J:5-a Right to External Review.
I. A covered person shall have the right to independent external review of a determination by a health carrier or its designee utilization review entity when all of the following conditions apply:
(a) The subject of the request for external review is an adverse determination;
(b) The covered person has completed the internal review procedures provided by the carrier or other licensed entity pursuant to RSA 420-J:5, or the carrier or other entity has agreed to submit the determination to independent external review prior to completion of internal review, or the covered person has requested first or second level, standard or expedited review and has not received a decision from the carrier or other licensed entity within the required time frames;
(c) (1) The covered person or the covered person's authorized representative has submitted the request for external review in writing to the commissioner within 180 days of the date of the carrier or other licensed entity's denial decision provided pursuant to RSA 420-J:5, or if the carrier or other licensed entity has failed to make a first or second level, standard or expedited review decision that is past due, within 180 days of the date the decision was due;
(2) The covered person's or covered person's authorized representative's participation in any voluntary level of appeal offered by a carrier or other licensed entity pursuant to RSA 420-J:5, V(e)(2) shall not affect a covered person's ability to submit a request for external review. In the event that a covered person or covered person's authorized representative elects to proceed with a voluntary appeal, that person shall have 180 days from the date the decision is rendered on the voluntary appeal to submit a request for external review.
(d) The covered person's cost for the service, supply or drug that is the subject of the adverse determination is, or is anticipated in a 12-month period to be, equal to or in excess of $400;
(e) The health carrier determination does not relate to any category of health care services that is excluded from the external review provisions of this chapter pursuant to paragraph II; and
(f) The request for external review is not based on a claim or allegation of provider malpractice, professional negligence, or other professional fault excluded from the external review provisions of this chapter pursuant to paragraph III.
II. Determinations relating to the following health care services shall not be reviewed under this chapter, but shall be reviewed pursuant to the review processes provided by applicable federal or state law:
(a) Health care services provided through Medicaid, the state Children's Health Insurance Program (Title XXI of the Social Security Act), Medicare or services provided under these programs but through a contracted health carrier.
(b) Health care services provided to inmates by the department of corrections.
(c) Health care services provided pursuant to a health plan not regulated by the state, such as self-funded plans administered by an administrative services organization or third-party administrator or federal employee benefit programs.
III. The external review procedures set forth in this chapter shall not be utilized to adjudicate claims or allegations of health care provider malpractice, professional negligence, or other professional fault against participating providers or medical directors.
Source. 2000, 18:13. 2001, 207:15. 2005, 248:21, eff. Sept. 12, 2005.