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) › § 9508 - Standard external review

(a)
(1) Not later than one hundred and twenty (120) days after the date of receipt of a notice of an adverse determination or final adverse determination, a covered person or enrollee may file a request for an external review with the Commissioner.
(2) Within one (1) business day after the date of receipt of a request for external review, the Commissioner shall send a copy of the request to the health insurance organization or issuer involved.
(b) Within five (5) business days following the date of receipt of the copy of the external review request, the health insurance organization or issuer shall complete a preliminary review of the request to determine whether:
(1) The individual is or was a covered person or enrollee in the health plan at the time the healthcare service was requested or, in the case of a retrospective review, was a covered person or enrollee in the health plan at the time the healthcare service was provided;
(2) the healthcare service that is the subject of the adverse determination or the final adverse determination is a covered service under the covered person or enrollee's health plan, but for a determination by the health insurance organization or issuer that the healthcare service is not covered because it does not meet the health insurance organization or issuer's requirements for medical necessity, appropriateness, healthcare setting, level of care or effectiveness;
(3) the covered person or enrollee has exhausted the health insurance organization or issuer's internal grievance process, unless it is not required to exhaust such internal grievance process pursuant to § 9507 of this title, and
(4) the covered person or enrollee has provided all the information and forms required by the Commissioner to process an external review, including the health information release form provided under § 9505(b)(3) of this title.
(c)
(1) Not later than one (1) business day after completion of the preliminary review, pursuant to subsection (b) of this section, the health insurance organization or issuer shall notify the Commissioner and the covered person or enrollee in writing whether:
(A) The request is complete, and
(B) the request is eligible for external review.
(2) If the request:
(A) Is not complete, the health insurance organization or issuer shall provide a notice of initial determination to the covered person or enrollee and the Commissioner in writing and include what information or materials are needed to make the request complete, or
(B) is not eligible for external review, the health insurance organization or issuer shall provide a notice of initial determination to the covered person or enrollee and the Commissioner in writing and include the reasons for its ineligibility.
(3)
(A) The Commissioner may specify the form and content of the notice of initial determination referred to in clause (2) of this subsection.
(B) If the health insurance organization or issuer determines, as a result of the preliminary review conducted pursuant to subsection (b) of this section that a request is not eligible for external review, the notice provided for such purposes to the covered person or enrollee shall include a statement informing the covered person or enrollee that the health insurance organization or issuer has made a determination of ineligibility and that it may be appealed to the Commissioner.
(4)
(A) The Commissioner may determine that a request is eligible for external review under subsection (b) of this section notwithstanding a health insurance organization or issuer's initial determination to the contrary.
(B) The decision of the Commissioner that a request is eligible for external review, after the initial determination of the health insurance organization or issuer to the contrary, shall be made in accordance with the terms of the health plan and shall be subject to all applicable provisions of this chapter.
(d)
(1) Not later than one (1) business day after the date of receipt of the notice, whenever the Commissioner receives a notice that a request is eligible for external review, he/she shall:
(A) Assign an independent review organization to conduct the external review and notify the health insurance organization or issuer of the name of the assigned independent review organization, and
(B) Notify in writing the covered person or enrollee of the request's eligibility and acceptance for external review.
(2) In reaching a decision, the assigned independent review organization is not bound by any decisions or conclusions reached during the health insurance organization or issuer's utilization review process or internal grievance process.
(3) The Commissioner shall include in the notice of request acceptance for external review provided to the covered person or enrollee a statement that he/she may submit in writing to the assigned independent review organization within five (5) business days following the date of receipt of the notice provided, additional information that the independent review organization shall consider when conducting the external review. The independent review organization is not required to, but may, accept and consider additional information submitted after five (5) business days, as provided herein.
(e)
(1) Not later than five (5) business days after the date of receipt of the notice, the health insurance organization or issuer shall provide to the assigned independent review organization the documents and any information considered in making the adverse determination or final adverse determination subject to external review.
(2) Except as provided in clause (3) of this subsection, failure by the health insurance organization or issuer to provide the documents and information required within five (5) business days as provided in clause (1) of this subsection, shall not delay the conduct of the external review.
(3)
(A) If the health insurance organization or issuer fails to provide the documents and information within five (5) business days as provided in clause (1) of this subsection, the independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination subject to external review.
(B) Not later than one (1) business day after making the decision to reverse the adverse determination or final adverse determination subject to external review, on the grounds provided in paragraph (A) of this clause, the independent review organization shall notify the covered person or enrollee, the health insurance organization or issuer, and the Commissioner.
(f)
(1) The independent review organization shall review all of the information and documents received from the health insurance organization or issuer and any other information submitted in writing by the covered person or enrollee.
(2) If the independent review organization receives information submitted by the covered person or enrollee, it shall forward such information to the health insurance organization or issuer involved not later than one (1) business day upon receipt of the information.
(g)
(1) Upon receipt of the information pursuant to subsection (f)(2) of this section, the health insurance organization or issuer may reconsider its adverse determination or final adverse determination that is the subject of the external review.
(2) Reconsideration by the health insurance organization or issuer of its adverse determination or final adverse determination shall not delay or terminate the external review.
(3) The external review may only be terminated if the health insurance organization or issuer decides, upon completion of its reconsideration, to reverse its adverse determination or final adverse determination and provide coverage or payment for the healthcare service that is the subject of the adverse determination or final adverse determination.
(4)
(A) Within one (1) business day after making the decision to reverse its adverse determination or final adverse determination, the health insurance organization or issuer shall notify the covered person or enrollee, the independent review organization, and the Commissioner in writing of its decision.
(B) The independent review organization shall terminate the external review upon receipt of the notice from the health insurance organization or issuer sent pursuant to paragraph (A) of this clause.
(h) In addition to the documents and information provided pursuant to subsection (e)(1) of this section, the independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall consider the following in reaching a decision:
(1) The covered person or enrollee's medical records;
(2) the covered person or enrollee's attending healthcare professional's recommendation;
(3) consulting reports from appropriate healthcare professionals and other documents submitted by the health insurance organization or issuer, the covered person or enrollee, or the covered person or enrollee's treating provider;
(4) the terms of coverage under the covered person or enrollee's health plan;
(5) the most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by the federal government, national or professional and medical societies, boards and associations;
(6) any applicable clinical review criteria developed and used by the health insurance organization or issuer or utilization review organization in making an adverse determination or final adverse determination, and
(7) the opinion of any independent review organization's clinical reviewer after considering the documents listed in clauses (1)–(6) of this subsection.
(i)
(1) Not later than forty-five (45) days after the date of receipt of the request for an external review, the independent review organization shall provide written notice of its decision to uphold or reverse the adverse determination or the final adverse determination subject of the review. The written notice shall be provided to:
(A) The covered person or enrollee.
(B) The health insurance organization or issuer.
(C) The Commissioner.
(2) The independent review organization shall include in the written notice:
(A) A general description of the reason for the request for external review;
(B) the date the independent review organization received the assignment from the Commissioner to conduct the external review;
(C) the date the external review was conducted;
(D) the date of its decision;
(E) the principal reason or reasons for its decision, including what applicable, if any, evidence-based standards were a basis for its decision;
(F) the rationale for its decision, and
(G) references to the evidence or documentation, including the evidence-based standards, considered in reaching its decision.
(3) Upon receipt of a notice from the independent review organization of a decision reversing the adverse determination or final adverse determination, the health insurance organization or issuer immediately shall approve coverage or payment of the service or benefit that was the subject of the review.
(j) The assignment by the Commissioner of an independent review organization to conduct an external review in accordance with this chapter shall be done on a random basis among those approved independent review organizations qualified to conduct the particular external review based on the nature of the healthcare service that is the subject of the adverse determination or final adverse determination being reviewed and other circumstances, including potential conflict of interests.
History —Aug. 29, 2011, No. 194, added as § 28.080 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.