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) › § 9509 - Expedited external review

(a) Except as provided in subsection (f) of this section, a covered person or enrollee may make a request for an expedited external review with the Commissioner at the time he/she receives:
(1) An adverse determination, if:
(A) The adverse determination involves a medical condition of the covered person or enrollee for which the timeframe for completion of an expedited internal review as provided 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, and
(B) the covered person or enrollee has filed a request for an expedited review of a grievance involving an adverse determination as set forth in § 9400 of this title, or
(2) A final adverse determination, if:
(A) 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, or
(B) the final adverse determination concerns an admission, availability of care, continued stay or healthcare service for which the covered person or enrollee received emergency services, but has not been discharged from a facility.
(b)
(1) Upon receipt of a request for an expedited external review, the Commissioner immediately shall send a copy of the request to the health insurance organization or issuer involved.
(2) Immediately upon receipt of the request for expedited external review, the health insurance organization or issuer shall determine whether the request meets the reviewability requirements set forth in § 9508 of this title, and immediately notify the Commissioner and the covered person or enrollee of its eligibility determination.
(3)
(A) The Commissioner may specify the form and content of the health insurance organization or issuer's notice of initial determination under clause (2) of this subsection.
(B) If the health insurance organization or issuer determines, as a result of the preliminary review conducted in accordance with clause (2) of this subsection, that an external review request is ineligible for external review, the notice provided to the covered person or enrollee shall include a statement informing him/her that the health insurance organization or issuer's determination of ineligibility may be appealed to the Commissioner.
(4)
(A) The Commissioner may determine that a request is eligible for external review notwithstanding a health insurance organization or issuer's initial determination to the contrary.
(B) In making a determination that a request is eligible for external review notwithstanding a health insurance organization or issuer's initial determination to the contrary, the Commissioner's decision shall be made in accordance with the terms of the covered person or enrollee's health plan and shall be subject to all applicable provisions of this chapter.
(5) Upon receipt of the notice of the health insurance organization or issuer that the request meets the reviewability requirements, the Commissioner shall immediately assign an independent review organization to conduct the expedited external review. The Commissioner shall immediately notify the health insurance organization or issuer of the name of the assigned independent review organization and notify in writing the covered person or enrollee that a request is eligible for review and was accepted for expedited external review.
(6) 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.
(c) Upon receipt of the notice from the Commissioner of the name of the assigned independent review organization, the health insurance organization or issuer shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination subject to expedited external review electronically or by any other available expeditious method.
(d) In addition to the documents and information set forth in subsection (c) of this section, the independent review organization, to the extent the information or documents are available and considers them appropriate, shall consider the following in reaching a decision:
(1) The covered person or enrollee's pertinent 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, covered person or enrollee, or his/her 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 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 adverse determinations, and
(7) the opinion of any independent review organization's clinical reviewer after considering the documents listed in clauses (1)–(6) above.
(e)
(1) As expeditiously as the covered person or enrollee's medical condition or circumstances requires, but in no event more than seventy-two (72) hours after the date of receipt of the request for an expedited external review, the assigned independent review organization shall:
(A) Make a decision to uphold or reverse the adverse determination or final adverse determination subject of review, and
(B) notify the covered person or enrollee, the health insurance organization or issuer, and the Commissioner of the decision.
(2) If the notice of the decision of the independent review organization is not initially made in writing, within forty-eight (48) hours after the determination, the independent review organization shall:
(A) Provide written confirmation of the decision to the covered person or enrollee, the health insurance organization or issuer, and the Commissioner, and
(B) include in the written notice the information set forth in § 9508(i)(2) of this title.
(3) If the decision of the independent review organization reverses the adverse determination or final adverse determination subject to review, the health insurance organization or issuer immediately shall approve the coverage or payment for the service or benefit that was the subject of the expedited external review.
(f) An expedited external review may not be available when the adverse determination or final adverse determination was a result of a retrospective review.
(g) The assignment by the Commissioner of an independent review organization to conduct an expedited 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 under review and other circumstances, including potential conflict of interests.
History —Aug. 29, 2011, No. 194, added as § 28.090 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.