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) › § 9400 - Expedited reviews of grievances involving an adverse determination

(a) Health insurance organizations or issuers shall establish written procedures for the expedited review of urgent care requests involving an adverse determination.
(b) The procedures shall allow a covered person or enrollee, or his/her authorized representative, to request an expedited review under this section to the health insurance organization or issuer either orally or in writing.
(c) A health insurance organization or issuer shall appoint an appropriate clinical peers in the same or similar specialty as would typically manage the case being reviewed to conduct the expedited review. Such clinical peers shall not have been involved in making the initial adverse determination.
(d) In an expedited review, all the necessary information, including the health insurance organization or issuer's decision, shall be transmitted between the health insurance organization or issuer and the covered person or enrollee or, if applicable, his/her authorized representative, by telephone, fax, or the most expeditious method available.
(e) An expedited review decision shall be made and the covered person or enrollee or, if applicable, his/her authorized representative, shall be notified of the decision in accordance with subsection (g) of this section as expeditiously as the covered person or enrollee's medical condition requires, but in no event in more than forty-eight (48) hours after the receipt of the request for the expedited review.
(f) For purposes of calculating the time periods within which a decision is required to be made and notified under subsection (e) of this section, the time period shall begin on the date the request for an expedited review is filed with the health insurance organization or issuer without regard to whether all of the information necessary to make the determination accompanies such filing.
(g)
(1) The notification of the decision shall describe the following, in a manner that is comprehensible to the covered person or enrollee or, if applicable, his/her authorized representative:
(A) The titles and qualifying credentials of the persons participating in the expedited review process (the reviewers);
(B) a statement of the reviewers' understanding of the covered person's request for an expedited review;
(C) the reviewers' decision in clear terms, and the contract basis or medical rationale for the covered person or enrollee to respond to the health insurance organization or issuer's position;
(D) a reference to the evidence or documentation used as the basis for the decision, and
(E) If the decision involves an adverse determination, the notice shall provide:
(i) The specific reasons for the final adverse determination.
(ii) Reference to the specific plan provisions on which the determination is based.
(iii) If the health insurance organization or issuer relied upon an internal rule, guideline, protocol, or other similar criterion to make the adverse determination, a copy of such specific rule, guideline, protocol or other similar criterion relied upon to make the adverse determination shall be provided, upon request and free of charge, to the covered person or enrollee.
(iv) If the final adverse determination is based on a medical necessity, experimental or investigational treatment, or similar exclusion or limit, an explanation of the scientific or clinical judgment for making the determination.
(v) If applicable, instructions for requesting:
(I) A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the adverse determination in accordance with subparagraph (iii) of this paragraph, or
(II) a written statement of the scientific or clinical rationale for the adverse determination in accordance with subparagraph (iv) of this paragraph.
(vi) A description of the procedures for obtaining an independent external review pursuant to the chapter on Health Insurance Organization or Issuer External Review of this Code.
(vii) A statement indicating the covered person's right to bring a civil action in a court of competent jurisdiction;
(viii) The following statement, stressing the voluntary nature of the procedures: “You and your health plan may have other voluntary alternative dispute resolution options, such as mediation or arbitration. One way to find out what may be available is to contact the Commissioner of Insurance”.
(ix) 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.
(2)
(A) A health insurance organization or issuer shall provide the notice required under this section orally, in writing, or electronically.
(B) If notice of the adverse determination is provided orally, the health insurance organization or issuer shall provide written or electronic notice within three (3) days following the oral notification.
(3) None of these provisions shall be construed to limit the power of a health insurance organization or issuer to render an adverse determination ineffective without following the procedure set forth herein.
History —Aug. 29, 2011, No. 194, § 22.100, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 30, eff. 30 days after July 10, 2013.