2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9399 - Voluntary level of reviews of grievances

(a)
(1) A health insurance organization or issuer that offers managed care plans shall establish a voluntary review process for its managed care plans to give those covered persons or enrollees who are dissatisfied with the first level review decision made pursuant to § 9397 of this title, or who are dissatisfied with the standard review decision made pursuant to § 9398 of this title, the option to request an additional voluntary review, at which they shall be entitled to appear before the designated representatives of the health insurance organization or issuer.
(2) This section shall not apply to health indemnity plans.
(b)
(1) A health insurance organization or issuer required by this section to establish a voluntary review process shall provide covered persons or enrollees, or their authorized representatives, with a notice pursuant to § 9397(g)(6) or § 9398(e)(5) of this title, as appropriate. Such notice shall indicate the option to file a request for an additional voluntary review.
(2) Upon receipt of a request for an additional voluntary review, the health insurance organization or issuer shall send notice to the covered person or enrollee or, if applicable, his/her authorized representative, of the covered person or enrollee's right to:
(A) Request, within the timeframe specified in clause (3)(A) of this subsection, the opportunity to appear in person before a review panel of the health insurance organization or issuer's designated representatives;
(B) receive from the health insurance organization or issuer, upon request, copies of all documents, records, and other information that is not confidential or privileged, related to the covered person or enrollee's request for an additional voluntary review;
(C) present the covered person or enrollee's case to the review panel;
(D) submit written comments, documents, records, and other material related to the request for an additional voluntary review for the review panel to consider both before and during the review meeting, if applicable;
(E) if applicable, ask questions to any representative of the health insurance organization or issuer on the review panel, and
(F) be assisted or represented by an individual of the covered person or enrollee's choice, including an attorney.
(3)
(A) A covered person or enrollee, or his/her authorized representative, who wishes to appear in person before the review panel shall make a written request to the health insurance organization or issuer not later than fifteen (15) business days after the receipt of the notice sent in accordance with clause (2) of this subsection.
(B) The covered person or enrollee's right to a fair review shall not be made conditional on such covered person or enrollee's appearance at the review.
(c)
(1)
(A) With respect to a request for voluntary review of a decision made pursuant to § 9397 of this title, a health insurance organization or issuer shall appoint a review panel to review the request.
(B) In conducting the review, the review panel shall take into consideration all comments, documents, records, and other information regarding the request for an additional voluntary review submitted by the covered person enrollee, or his/her authorized representative, without regard to whether the information was submitted or considered in making the first level review decision.
(C) The panel shall have the legal authority to bind the health insurance organization or issuer to the panel's decision. If, after twenty (20) calendars days, the health insurance organization or issuer fails to comply with the decision of the review panel, the latter shall notify such fact to the Commissioner.
(2)
(A) Except as provided in paragraph (B) of this clause, a majority of the panel shall be comprised of individuals who were not involved in the first level review decision made pursuant to § 9397 of this title.
(B) An individual who was involved in the first level review decision may be a member of the panel or appear before the same to present information or answer questions.
(C) The health insurance organization or issuer shall ensure that the individuals conducting the additional voluntary review are healthcare professionals with the appropriate expertise.
(D) The individuals conducting the additional voluntary review shall not:
(i) Be a provider in the covered person or enrollee's health plan, or
(ii) have a financial interest in the outcome of the review.
(d)
(1)
(A) With respect to a request for an additional voluntary review of a decision made pursuant to § 9398 of this title, a health insurance organization or issuer shall appoint a review panel to review the request.
(B) The panel shall have the legal authority to bind the health insurance organization or issuer to the panel's decision. If, after twenty (20) calendars days, the health insurance organization or issuer fails to comply with the decision of the review panel, the latter shall notify such fact to the Commissioner.
(2)
(A) Except as provided in paragraph (B) of this clause, a majority of the panel shall be comprised of employees or representatives of the health insurance organization or issuer who were not involved in the standard review conducted pursuant to § 9398 of this title.
(B) An employee or representative of the health insurance organization or issuer who participated in the standard review may be a member of the panel or appear before the same to present information or answer questions.
(e)
(1)
(A) Whenever a covered person or enrollee, or his/her authorized representative, requests, within the timeframe specified in subsection (c) or (d) of this section, to appear in person before the review panel, the procedures for conducting the additional voluntary review shall be governed by the provisions described hereinbelow.
(B)
(i) The review panel shall schedule and hold a review meeting not later than thirty (30) calendar days after the receipt of the request for an additional voluntary review.
(ii) The covered person or enrollee or, if applicable, his/her authorized representative, shall be notified in writing, at least fifteen (15) business days in advance, of the date of the review meeting.
(iii) The health insurance organization or issuer shall not unreasonably deny a request for postponement of the review made by the covered person enrollee, or his/her authorized representative.
(C) The review meeting shall be held during regular business hours at a location reasonably accessible to the covered person or enrollee or, if applicable, his/her authorized representative.
(D) In cases where a face-to-face meeting is not practical for geographic reasons, a health insurance organization or issuer shall offer the covered person or enrollee or, if applicable, his/her authorized representative, the opportunity to communicate with the review panel, at the health insurance organization or issuer's expense, by conference call, video conferencing, or other appropriate technology.
(E) If the health insurance organization or issuer intends to have legal representation, such health insurance organization or issuer shall notify the covered person or enrollee or, if applicable, his/her authorized representative, at least fifteen (15) calendar days in advance of the date of the review meeting. It shall also notify the covered person or enrollee that he/she may obtain legal representation of his/her own.
(F) The review panel shall issue a written decision, as provided in subsection (f) of this section, to the covered person or enrollee or, if applicable, his/her authorized representative, not more than ten (10) business days of completing the review meeting.
(2) Whenever the covered person or enrollee or, if applicable, his/her authorized representative, does not request the opportunity to appear in person before the review panel, such panel shall issue a decision and notify it in writing or electronically (if it has been agreed to thus notify this decision) as provided in subsection (f) of this section, within forty-five (45) calendar days after the earlier of:
(A) The date on which the covered person or enrollee, or his/her authorized representative, notifies the health insurance organization or issuer of the decision not to appear in person before the review panel, or
(B) the date on which the covered person's or enrollee's, or his/her authorized representative's opportunity to request to appear in person before the review panel expires, pursuant to subsection (b)(3)(A) of this section.
(f) The written decision issued pursuant to subsection (e) shall contain:
(1) The titles and qualifying credentials of the members of the review panel.
(2) A statement of the review panel's understanding of the request for an additional voluntary review and all pertinent facts.
(3) The rationale for the review panel's decision.
(4) A reference to evidence or documentation considered by the review panel in making that decision.
(5) In cases concerning a request for an additional voluntary review involving an adverse determination:
(A) The instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination, and
(B) if applicable, a statement describing the procedures for obtaining an independent external review of the adverse determination pursuant to the chapter on Health Insurance Organization or Issuer External Review of this Code.
(6) Notice of the covered person or enrollee’s right to contact the Office of the Insurance Commissioner and the Office of the Patient’s Advocate for assistance with respect to any claim, grievance or appeal at any time, including the telephone number and address of the Office of the Insurance Commissioner and the Office of the Patient’s Advocate.
History —Aug. 29, 2011, No. 194, § 22.090, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 29, eff. 30 days after July 10, 2013.