strued to permit an independent medical re-
viewer to require that a group health plan, or 
health insurance issuer offering health insur-
ance coverage, provide coverage for items or 
services for which benefits are specifically ex-
cluded or expressly limited under the plan or 
coverage in the plain language of the plan docu-
ment (and which are disclosed under section 
121(b)(1)(C)). Notwithstanding any other pro-
vision of this Act, any exclusion of an exact 
medical procedure, any exact time limit on the 
duration or frequency of coverage, and any 
exact dollar limit on the amount of coverage 
that is specifically enumerated and defined (in 
the plain language of the plan or coverage docu-
ments) under the plan or coverage offered by a 
group health plan or health insurance issuer of-
fering health insurance coverage and that is 
disclosed under section 121(b)(1) shall be con-
sidered to govern the scope of the benefits that 
may be required: Provided, That the terms and 
conditions of the plan or coverage relating to 
such an exclusion or limit are in compliance 
with the requirements of law.
(D) EVIDENCE AND INFORMATION TO BE 
USED IN MEDICAL REVIEWS.—In making a de-
termination under this subsection, the inde-
pendent medical reviewer shall also consider ap-
propriate and available evidence and informa-
tion, including the following: 
(i) The determination made by the 
plan or issuer with respect to the claim 
upon internal review and the evidence, 
guidelines, or rationale used by the plan or 
issuer in reaching such determination. 
(ii) The recommendation of the treat-
ing health care professional and the evi-
dence, guidelines, and rationale used by 
the treating health care professional in 
reaching such recommendation. 
(iii) Additional relevant evidence or 
information obtained by the reviewer or 
submitted by the plan, issuer, participant, 
beneficiary, or enrollee (or an authorized 
representative), or treating health care 
professional. 
(iv) The plan or coverage document. 
(E) INDEPENDENT
DETERMINATION.—In 
making determinations under this section, a
qualified external review entity and an inde-
pendent medical reviewer shall— 
(i) consider the claim under review 
without deference to the determinations 
made by the plan or issuer or the rec-
ommendation of the treating health care 
professional (if any); and 
(ii) consider, but not be bound by, the 
definition used by the plan or issuer of 
‘‘medically necessary and appropriate’’, or 
‘‘experimental or investigational’’, or other 
substantially equivalent terms that are 
used by the plan or issuer to describe med-
ical necessity and appropriateness or ex-
perimental or investigational nature of the 
treatment. 
(F) DETERMINATION
OF
INDEPENDENT 
MEDICAL REVIEWER.—An independent medical 
reviewer shall, in accordance with the deadlines 
described in subsection (e), prepare a written 
determination to uphold, reverse, or modify the 
denial under review. Such written determination 
shall include— 
(i) the determination of the reviewer;
(ii) the specific reasons of the re-
viewer for such determination, including a 
summary of the clinical or scientific evi-
dence used in making the determination; 
and 
(iii) with respect to a determination to 
reverse or modify the denial under review, 
a timeframe within which the plan or 
issuer must comply with such determina-
tion. 
(G) NONBINDING NATURE OF ADDITIONAL 
RECOMMENDATIONS.—In addition to the deter-
mination under subparagraph (F), the reviewer 
may provide the plan or issuer and the treating 
health care professional with additional rec-
ommendations in connection with such a deter-
mination, but any such recommendations shall 
not affect (or be treated as part of) the deter-
mination and shall not be binding on the plan 
or issuer. 
(e) TIMELINES AND NOTIFICATIONS.— 
(1) TIMELINES
FOR
INDEPENDENT
MEDICAL 
REVIEW.— 
(A) PRIOR
AUTHORIZATION
DETERMINA-
TION.—
(i) IN
GENERAL.—The independent 
medical reviewer (or reviewers) shall make 
a determination on a denial of a claim for 
benefits that is referred to the reviewer 
under subsection (c)(3) in accordance with 
the medical exigencies of the case and as 
soon as possible, but in no case later than 
14 days after the date of receipt of infor-
mation under subsection (c)(2) if the re-
view involves a prior authorization of items 
or services and in no case later than 21 
days after the date the request for external 
review is received. 
(ii) EXPEDITED
DETERMINATION.— 
Notwithstanding clause (i) and subject to 
clause (iii), the independent medical re-
viewer (or reviewers) shall make an expe-
dited determination on a denial of a claim 
for benefits described in clause (i), when a 
request for such an expedited determina-
tion is made by a participant, beneficiary, 
or enrollee (or authorized representative) 
at any time during the process for making 
a determination, and a health care profes-
sional certifies, with the request, that a de-
termination under the timeline described in 
clause (i) would seriously jeopardize the 
life or health of the participant, bene-
ficiary, or enrollee or the ability of the par-
ticipant, beneficiary, or enrollee to main-
tain or regain maximum function. Such de-
termination shall be made in accordance 
with the medical exigencies of the case and 
as soon as possible, but in no case later 
than 72 hours after the time the request 
for external review is received by the quali-
fied external review entity. 
(iii) 
ONGOING
CARE
DETERMINA-
TION.—Notwithstanding clause (i), in the 
case of a review described in such clause 
that involves a termination or reduction of 
care, the notice of the determination shall 
be completed not later than 24 hours after 
the time the request for external review is 
received by the qualified external review 
entity and before the end of the approved 
period of care. 
(B) RETROSPECTIVE
DETERMINATION.— 
The independent medical reviewer (or review-
ers) shall complete a review in the case of a ret-
rospective determination on an appeal of a de-
nial of a claim for benefits that is referred to 
the reviewer under subsection (c)(3) in no case 
later than 30 days after the date of receipt of 
information under subsection (c)(2) and in no 
case later than 60 days after the date the re-
quest for external review is received by the 
qualified external review entity. 
(2) NOTIFICATION
OF
DETERMINATION.—The 
external review entity shall ensure that the plan or 
issuer, the participant, beneficiary, or enrollee (or 
authorized representative) and the treating health 
care professional (if any) receives a copy of the writ-
ten determination of the independent medical re-
viewer prepared under subsection (d)(3)(F). Nothing 
in this paragraph shall be construed as preventing 
an entity or reviewer from providing an initial oral 
notice of the reviewer’s determination. 
(3) FORM
OF
NOTICES.—Determinations and 
notices under this subsection shall be written in a 
manner calculated to be understood by a participant. 
(f) COMPLIANCE.— 
(1) APPLICATION OF DETERMINATIONS.— 
(A) EXTERNAL REVIEW DETERMINATIONS 
BINDING ON PLAN.—The determinations of an
external review entity and an independent med-
ical reviewer under this section shall be binding 
upon the plan or issuer involved. 
(B) 
COMPLIANCE
WITH
DETERMINA-
TION.—If the determination of an independent 
medical reviewer is to reverse or modify the de-
nial, the plan or issuer, upon the receipt of such 
determination, shall authorize coverage to com-
ply with the medical reviewer’s determination in 
accordance with the timeframe established by 
the medical reviewer. 
(2) FAILURE TO COMPLY.— 
(A) IN GENERAL.—If a plan or issuer fails 
to comply with the timeframe established under 
paragraph (1)(B) with respect to a participant, 
beneficiary, or enrollee, where such failure to 
comply is caused by the plan or issuer, the par-
ticipant, beneficiary, or enrollee may obtain the 
items or services involved (in a manner con-
sistent with the determination of the inde-
pendent external reviewer) from any provider 
regardless of whether such provider is a partici-
pating provider under the plan or coverage. 
(B) REIMBURSEMENT.—
(i) IN
GENERAL.—Where a partici-
pant, beneficiary, or enrollee obtains items 
or services in accordance with subpara-
graph (A), the plan or issuer involved shall 
provide for reimbursement of the costs of 
such items or services. Such reimburse-
ment shall be made to the treating health 
care professional or to the participant, ben-
eficiary, or enrollee (in the case of a partic-
ipant, beneficiary, or enrollee who pays for 
the costs of such items or services). 
(ii) AMOUNT.—The plan or issuer 
shall fully reimburse a professional, partici-
pant, beneficiary, or enrollee under clause 
(i) for the total costs of the items or serv-
ices provided (regardless of any plan limi-
tations that may apply to the coverage of 
such items or services) so long as the items 
or services were provided in a manner con-
sistent with the determination of the inde-
pendent medical reviewer. 
(C) FAILURE
TO
REIMBURSE.—Where a 
plan or issuer fails to provide reimbursement to 
a professional, participant, beneficiary, or en-
rollee in accordance with this paragraph, the
professional, participant, beneficiary, or enrollee 
may commence a civil action (or utilize other 
remedies available under law) to recover only 
the amount of any such reimbursement that is 
owed by the plan or issuer and any necessary 
legal costs or expenses (including attorney’s 
fees) incurred in recovering such reimburse-
ment. 
(D) AVAILABLE REMEDIES.—The remedies 
provided under this paragraph are in addition 
to any other available remedies. 
(3) PENALTIES
AGAINST
AUTHORIZED
OFFI-
CIALS FOR REFUSING TO AUTHORIZE THE DETER-
MINATION OF AN EXTERNAL REVIEW ENTITY.— 
(A) MONETARY PENALTIES.— 
(i) IN
GENERAL.—In any case in 
which the determination of an external re-
view entity is not followed by a group 
health plan, or by a health insurance issuer 
offering health insurance coverage, any 
person who, acting in the capacity of au-
thorizing the benefit, causes such refusal 
may, in the discretion of a court of com-
petent jurisdiction, be liable to an ag-
grieved participant, beneficiary, or enrollee