Section 58-17C-94 - Appointment of panel for voluntary review of first level review decision--Scope of review--Composition of panel.
58-17C-94. Appointment of panel for voluntary review of first level review decision--Scope of review--Composition of panel. With respect to a voluntary review of a first level review decision made pursuant to §§ 58-17C-83 to 58-17C-86, inclusive, a health carrier shall appoint a review panel to review the request. In conducting the review, the review panel shall take into consideration all comments, documents, records, and other information regarding the request for benefits submitted by the covered person or the covered person's authorized representative pursuant to § 58-17C-93, without regard to whether the information was submitted or considered in reaching the first level review decision. The decision of the panel is legally binding on the health carrier.
Except for an individual who was involved with the first level review decision who may be a member of the panel or appear before the panel to present information or answer questions, a majority of the panel shall be comprised of individuals who were not involved in the first level review decision made pursuant to §§ 58-17C-83 to 58-17C-86, inclusive.
The health carrier shall ensure that a majority of the individuals conducting the additional voluntary review of the first level review decision made pursuant to §§ 58-17C-83 to 58-17C-86, inclusive, are health care professionals who have appropriate expertise. If a reviewing health care professional with the expertise required by this section is not reasonably available and there has been a denial of a health care service, the reviewing health care professional is only ineligible to review decisions if the professional meets both of the following criteria:
(1) The professional is a provider in the covered person's health benefit plan; and
(2) The professional has financial interest in the outcome of the review.
Source: SL 2003, ch 250, § 45; SL 2004, ch 304, § 1; SL 2008, ch 264, § 1.