Sec 20-2535. Informal reconsideration

A. Any member who is denied a service and who does not qualify for an expedited medical review pursuant to section 20-2534 may request, either orally or in writing, an informal reconsideration of that denial by notifying the person described in section 20-2533, subsection C, paragraph 3. After the denial, the member has up to two years to request an informal reconsideration. A health care insurer whose utilization review consists only of claims review for services already provided is not required to provide its members an informal reconsideration 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 informal reconsideration of a claim related to a service already provided.

B. The utilization review agent shall mail a written acknowledgment to the member and the member's treating provider within five business days after the utilization review agent receives the request for informal reconsideration.

C. The utilization review agent may request any pertinent medical records pursuant to title 12, chapter 13, article 7.1 that are necessary for the informal reconsideration.

D. The utilization review agent has up to thirty days after receipt of the request for reconsideration to mail to the member and the member's treating provider a notice of the utilization review agent's decision and the criteria used and the clinical reasons for that decision.

E. At any time during the informal reconsideration 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 decision and shall send the written decision, including the criteria used and the clinical reasons for that decision 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 informal reconsideration 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 criteria used and the clinical reasons for that decision, including any references to any supporting documentation and a notice of the option to proceed after the formal appeal process to an external independent 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 decision.