A patient who is denied care in the plan's internal process may appeal their case to an external review body. This bill outlines the basic criteria external review organizations must meet and the guidelines for operation of the external appeals process. The process must be independent of the health plan and the reviewers must use an objective standard of professional medical practice. The reviewers must meet strict conflict of interest standards and must also be appropriately knowledgeable of the medical issues in question. The review decision is binding on the plan.
Any decision involving a medical judgment is appealable.
However, if a benefit is specifically excluded from contract by a plan, it cannot be appealed . The clinical peers who review the patient's case must examine the patient's medical history and relevant plan documents. This subtitle creates basic rights for Americans in private health insurance. The bill guarantees every American the right to chose their own health professional. It guarantees every American access to specialty care.