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) › § 9505 - Notice of right to external review

(a)
(1) A health insurance organization or issuer shall notify the covered persons or enrollees in writing of the covered person or enrollee's right to request an external review to be conducted pursuant to this chapter. Such notification shall be made when the health insurance organization or issuer sends written notice of any of the following:
(A) An adverse determination upon completion of the utilization review process set forth in §§ 9421–9433 of this title.
(B) A final adverse determination.
(C) In the event of recission of coverage.
(2) As part of the written notice required under clause (1) above, a health insurance organization or issuer shall include the following, or substantially equivalent, language:
“We have denied your request for the provision of or payment for a healthcare service or course of treatment. You may have the right to have our decision reviewed by healthcare professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, healthcare setting, level of care or effectiveness of the healthcare service or treatment you requested by submitting a request for external review to the Office of the Insurance Commissioner. If you need additional information, you may contact the Office of the Insurance Commissioner of Puerto Rico.” If the health insurance organization or issuer, in compliance with federal law, has contracted an independent review organization or has availed itself of the independent review established by the Federal Department of Health, the notice shall be modified to specify the entity and contact information to which the enrollee shall submit an application for external review. A health insurance organization or issuer shall have sixty (60) days after the effective date of this chapter to notify the Office of the Insurance Commissioner of the independent external review procedure chosen. In the event that a private independent review organization is contracted, the name and credentials of the contracted organizations shall be specified.
(3) The Commissioner shall provide the form and content of the notice required under this section.
(b)
(1) The health insurance organization or issuer shall include in the notice required under subsection A, as appropriate:
(A) For a notice related to an adverse determination, a statement informing the covered person or enrollee, as applicable, that:
(i) If the covered person or enrollee has a medical condition where the timeframe for completion of an expedited review of a grievance, as set forth in § 9400 of this title, would seriously jeopardize the life or health of the covered person or enrollee or his/her ability to regain maximum function, the covered person or enrollee may file a request for an expedited external review to be conducted pursuant to § 9509 of this title or § 9510 of this title, as appropriate. In these cases, the independent review organization assigned to conduct the expedited external review shall determine whether the covered person or enrollee shall be required to complete the expedited review of the grievance, as provided in § 9400 of this title, prior to conducting the expedited external review, and
(ii) the covered person or enrollee may file a grievance under the health insurance organization or issuer's internal grievance process as set forth in § 9397 of this title. However, if the health insurance organization or issuer has not issued a written decision within thirty (30) days following the date the covered person or enrollee files the grievance, the covered person or enrollee may file a request for external review, since it shall be considered to have exhausted the internal grievance process for purposes of § 9507 of this title.
(B) For a notice related to a final adverse determination, a statement informing the covered person or enrollee, as applicable, that:
(i) If the covered person or enrollee has a medical condition where the timeframe for completion of a standard external review pursuant to § 9508 of this title, would seriously jeopardize the life or health of the covered person or enrollee or his/her ability to regain maximum function, the covered person or enrollee may file a request for an expedited external review pursuant to § 9509 of this title, or
(ii) if the final adverse determination concerns:
(I) Emergency services received in a healthcare facility, from which the covered person or enrollee has not been discharged, he/she may request an expedited external review pursuant to § 9509 of this title, or
(II) a denial of coverage based on a determination that the recommended or requested healthcare service or treatment is experimental or investigational, the covered person or enrollee may file a request for a standard external review to be conducted pursuant to § 9510 of this title, or if the covered person or enrollee's treating physician certifies in writing that the recommended or requested healthcare service or treatment that is the subject of the request would be significantly less effective if not promptly initiated, the covered person or enrollee may request an expedited external review to be conducted under § 9510 of this title.
(2) In addition to the information to be provided pursuant to subsections (a) and (b) of this section, the health insurance organization or issuer shall include a description of both the standard and expedited external review procedures highlighting the provisions that give the covered person or enrollee the opportunity to submit additional information. It shall also include the forms used to process an external review, if any.
(3) As part of any forms provided under clause (2) of this subsection, the health insurance organization or issuer shall include an authorization form, or other document approved by the Commissioner whereby the covered person or enrollee authorizes the health insurance organization or issuer to disclose protected health information, including medical records, that are pertinent to the external review.
History —Aug. 29, 2011, No. 194, added as § 28.050 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.