(2) by inserting ‘‘(other than a group health
plan)’’ after ‘‘employee benefit plan’’; and
(3) by adding at the end the following new sub-
sections:
‘‘(b) SPECIAL RULES FOR GROUP HEALTH PLANS.—
‘‘(1) IN GENERAL.—The claims procedures re-
quired by this section shall include—
‘‘(A) notification to a participant or bene-
ficiary of the participant or beneficiary’s right
to appeal an adverse determination to a utiliza-
tion review agent;
‘‘(B) notification to a participant or bene-
ficiary of the participant or beneficiary’s right
to appeal an adverse determination of a utiliza-
tion review agent to an independent review or-
ganization;
‘‘(C) notification to a participant or bene-
ficiary of the procedures for appealing an ad-
verse determination to an independent review
organization;
‘‘(D) notification to a participant or bene-
ficiary who has a life-threatening condition of
the participant or beneficiary’s right to imme-
diate review by an independent review organiza-
tion and the procedures to obtain such review;
and
‘‘(E) procedures for a fair, de novo deter-
mination of medical necessity by the inde-
pendent review organization without regard to
the definition used by the plan.
‘‘(c) APPEAL OF ADVERSE DETERMINATION.—In a
case in which an employee benefit plan denies a claim for
benefits under the plan to a participant or beneficiary,
such participant or beneficiary may appeal such adverse
determination to a utilization review agent. The proce-
dures for appeals shall be reasonable and shall include the
following:
‘‘(1) A provision indicating that a participant or
beneficiary, a person acting on behalf of the partici-
pant or beneficiary, or the participant or bene-
ficiary’s physician or health care provider may ap-
peal the adverse determination orally or in writing.
‘‘(2) A provision that the utilization review
agent shall send to the appealing party, within 5
working days after receipt of a written appeal, a let-
ter acknowledging the date of the utilization review
agent’s receipt of the appeal and including a reason-
able list of documents needed to be submitted by the
appealing party to the utilization review agent for
the appeal.
‘‘(3) In a case in which a utilization review
agent receives an oral appeal of adverse determina-
tion, the utilization review agent shall send a one
page appeal form to the appealing party.
‘‘(4) A provision that appeal decisions shall be
made by a physician, provided that, if the appeal is
denied and within 10 working days the health care
provider sets forth in writing good cause for having
a particular type of a specialty provider review the
case, the denial shall be reviewed by a health care
provider in the same or similar specialty as typically
manages the medical, dental, or specialty condition,
procedure, or treatment under discussion for review
of the adverse determination, and such specialty re-
view shall be completed within 15 working days of
receipt of the request.
‘‘(5) A method for an expedited appeal proce-
dure for emergency care denials, denials of care for
life threatening conditions, and denials of continued
stays for hospitalized patients. Such procedure shall
include a review by a health care provider who has
not previously reviewed the case who is of the same
or a similar specialty as typically manages the med-
ical condition, procedure, or treatment under review.
The time frame in which such appeal must be com-
pleted shall be based on the medical or dental imme-
diacy of the condition, procedure, or treatment, but
may in no event exceed one working day from the
date all information necessary to complete the ap-
peal is received.
‘‘(6) A provision that after the utilization re-
view agent has sought review of the appeal of the
adverse determination, the utilization review agent
shall issue a response letter to the patient, person
acting on behalf of the patient, or the patient’s phy-
sician or health care provider explaining the resolu-
tion of the appeal. Such letter shall include a state-
ment of the specific medical, dental, or contractual
reasons for the resolution, the clinical basis for such
decision, and the specialization of any physician or
other provider consulted.
‘‘(7) Written notification to the appealing party
of the determination of the appeal, as soon as prac-
tical, but in no case later than 30 days after the
date of the utilization review agent receives the ap-
peal.
‘‘(d) INDEPENDENT REVIEW OF ADVERSE DETER-
MINATIONS.—
‘‘(1) IN GENERAL.—In a case in which an ap-
peal of an adverse determination is denied by a utili-
zation review agent, a participant or beneficiary may
seek review of such adverse determination from an
independent review organization.
‘‘(2) ELEMENTS
OF
INDEPENDENT
REVIEW
PROCESS.—
‘‘(A) IN GENERAL.—The independent re-
view process under this subsection shall be con-
ducted by an independent review organization
and shall ensure—
‘‘(i) a timely response by the inde-
pendent review organization;
‘‘(ii) confidentiality of medical records
transmitted for use in the review process;
‘‘(iii) the independence of each health
care provider or physician making review
determinations as part of an independent
review organization; and
‘‘(iv) timely notice to the participant
or beneficiary of the results of the inde-
pendent review, including the clinical basis
for the determination.
‘‘(B) INFORMATION
PROVIDED
TO
THE
INDEPENDENT
REVIEW
ORGANIZATION.—Not