Louisiana Administrative Code › Title 37 - INSURANCE › Part XIII - Regulations › Chapter 62 - Regulation Number 103-Utilization Review Organizations and Independent Review Organizations › Section XIII-6209 - Requesting an External Review

Current through Register Vol. 50, No. 6, June 20, 2024
A. All
				requests for external review must be made by the health insurance issuer
				through the IRO review request module, which can be accessed via the industry
				access link on the LDI's website:
www.ldi.la.gov
. When a covered person or
				his authorized representative requests an external review, the health insurance
				issuer shall notify the LDI by entering this request via the link. The request
				must be entered even if the health insurance issuer determines the request is
				ineligible for review.
B. If the
				covered person or his authorized representative requests an external review,
				but the health insurance issuer determines that the request is not complete,
				the health insurance issuer shall notify the LDI through the IRO review request
				module described in
				§6209.A by completing
				the field indicating that the covered person's or his authorized
				representative's request is incomplete and stating with specificity the
				information or materials needed to make the request complete. Such notice shall
				be provided to the LDI within five business days following the date of receipt
				of the external review request from the covered person or his authorized
				representative pursuant to
				R.S.
				22:2436.
C. If the covered person or his authorized
				representative requests an external review, but the health insurance issuer
				denies the request as being ineligible pursuant to
				R.S.
				22:2436(B), the covered
				person or his authorized representative may appeal in writing to the
				commissioner. The health insurance issuer and the covered person or his
				authorized representative both may submit additional documentation, such as the
				policy to verify coverage limitations as well as dates of coverage,
				documentation of service dates, etc., to help establish why the denial should
				be upheld or reversed. However, no medical or protected health information
				should be submitted to the commissioner for this review, unless such
				information is determinative of the issue in the appeal.
D. Upon receipt of an appeal of a health
				insurance issuer's eligibility determination, the LDI may contact the health
				insurance issuer's designated contact to request additional information, if
				necessary. Therefore, all health insurance issuers should ensure that the
				designated contact's information is regularly updated in the industry access
				portal, as all electronic communications, including assignment of a case to an
				IRO, reporting of an IRO's external review results, reporting of the
				commissioner's decision on eligibility for an external review, etc., will be
				sent automatically to the designated contact of record that is on file with the
				LDI.
E. To facilitate notice of the
				right to appeal a determination of ineligibility to the commissioner, the
				health insurance issuer shall include the reason for ineligibility, as well as
				the following language (or language that is substantially similar), in its
				notice to the covered person.
"[Name of health insurance issuer] has determined that your
				  request for an independent external review of your adverse determination does
				  not meet the eligibility requirements for independent external reviews because
				  [reason]. However, [name of health insurance issuer]'s determination that you
				  are ineligible for an external review may be appealed to the Commissioner of
				  Insurance, who has the authority to reverse [name of health insurance issuer]'s
				  decision and order an independent external review of your adverse
				  determination. If you wish to appeal this decision, you should go to the
				  following website:
https://ldi.la.gov/OnlineServices/
IROConsumerAppeals.
Once you access the website, enter your last name and case
				  number where instructed. Following verification of your name and case number,
				  you will be able to enter the reasons you believe your adverse determination
				  should be eligible for an independent external review. If you have questions or
				  if you or your authorized representative is unable to access the website, you
				  may contact the Louisiana Department of Insurance by email at
				  ConsumerAppeals@ldi.la.gov or by telephone at (225) 342-1355. Your case number
				  is _______ ."
1. Health insurance
				issuers must also upload a copy of the adverse determination letter when
				reporting external review requests that have been deemed ineligible.