2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9507 - Exhaustion of internal grievance process

(a)
(1) Except as provided in subsection (b) of this section, a request for an external review shall not be made until the covered person or enrollee has exhausted the health insurance organization or issuer's internal grievance process.
(2) For purposes of this section, the health insurance organization or issuer's internal grievance process shall be considered to have been exhausted, if the covered person or enrollee:
(A) Has filed a grievance pursuant to § 9397 of this title, and
(B) the covered person or enrollee has not received a written decision on the grievance from the health insurance organization or issuer within thirty (30) days following the date he/she filed the grievance, unless an extension or delay has been agreed upon.
(3) Notwithstanding the above clause (2) of this subsection, a covered person or enrollee may not make a request for an external review of an adverse determination involving a retrospective review determination made pursuant to §§ 9421–9434 of this title until he/she has exhausted the health insurance organization or issuer's internal grievance process.
(b)
(1)
(A) At the same time a covered person or enrollee files a request for an expedited review of a grievance as set forth in § 9400 of this title, he/she may file a request for an expedited external review, in accordance with any of the following:
(i) Under § 9509 of this title, if the covered person or enrollee has a medical condition where the timeframe for completion of an expedited review of the grievance would seriously jeopardize the life or health of the covered person or enrollee or his/her ability to regain maximum function, or
(ii) under § 9510 of this title, if the adverse determination involves a denial of coverage based on a determination that the recommended or requested healthcare service or treatment is experimental or investigational and the covered person or enrollee's treating physician certifies in writing that healthcare service or treatment would be significantly less effective if not promptly initiated.
(B) Upon receipt of a request for an expedited external review under paragraph (A) of this clause, the independent review organization designated to conduct the external review shall determine whether the covered person or enrollee shall be required to complete the expedited internal review process first.
(C) If the independent review organization determines that the covered person or enrollee shall complete the expedited internal review process first, it shall immediately notify the covered person or enrollee of this determination and that it will not proceed with the expedited external review until completion of the expedited grievance review process.
(2) A request for an external review of an adverse determination may be made before the covered person or enrollee has exhausted the health insurance organization or issuer's internal grievance procedures, provided that the health insurance organization or issuer agrees to waive the exhaustion requirement.
(c) If the requirement to exhaust the health insurance organization or issuer's internal grievance procedures is waived, the covered person or enrollee may file a request in writing for a standard external review.
History —Aug. 29, 2011, No. 194, added as § 28.070 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.