External Review - Kaiser State Health Facts

Patients' Rights: External Review, 2008

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	Mandates External Review?	Applies to:	Type of Grievance	Filing Time Limit	Filing Fee	State Authority

United States	44 + DC Yes

Alabama	Yes	Any HMO	Any denial of benefits or claims	None	$0	The State Complaint Committee through the State Health Officer.
Alaska	Yes	Any managed care organization	Any denial of benefits or claims based on medical necessity, investigational or experimental status, decisions involving a medical judgment or if internal appeal filing deadline was missed.	None	$0	The Director of the Department of Insurance.
Arizona	Yes	Any health plan	Any denial of a covered service or claim for a covered service.	Within 30 days of written notice of final denial by the health plan.	$0	The Director of the Department of Insurance.
Arkansas	Yes	Any health plan	Any adverse determination. The regulations require that all internal appeal options be exhausted before proceeding to the external review alternative. Allowances have also been made for an expedited review if the covered person requests. Other provisions in the regulations establish that the decisions are binding on the health carrier and the covered person and also includes the process of approval to be certified as a independent review organization. The rules have a compliance date of January 1, 2003.	Within 60 days of notification.	Except in an expediated appeal, $25.	The Director of the Department of Insurance.
California	Yes	Any health plan	Any denial of service if the decision was based on a finding that the service was not medically necessary.	Within 6 months of a denial of service or delayed determination of an appeal	$0	The Department of Managed Health Care and the Department of Insurance.
Colorado	Yes	Any health plan	Any denial of a covered service on the basis that the service is not medically necessary or medically effective.	Within 60 days of second level appeal denial from the health plan.	$0	The State Insurance Commissioner.
Connecticut	Yes	Any managed care organization	Any denial of a covered service.	Within 60 days of final notice of denial by the managed care organization.	$25	The Insurance Commissioner.
Delaware	Yes	Any health carrier	Any denial of a covered benefits.	Within 60 days of the final denial by the health carrier.	$0	The Independent Health Care Appeals Program.
District of Columbia	Yes	Any health plan	Any denial, termination or limitation of a health care service.	30 Days.	$0	The Department of Health.
Florida	Yes	Any HMO	Any denial of coverage or claim.	None	$0	The Statewide Providers and Subscribers Assistance Panel.
Georgia	Yes	Any managed care plan	Any denial for covered services or if the treatment is excluded as experimental.	None	$0	The Health Planning Agency. 1
Hawaii	Yes	Any managed care plan	Any denial for services or if the treatment if excluded as experimental.	Within 30 days of final notice of denial by the plan.	$0	The State Insurance Commissioner.
Idaho	No	NA	NA	NA	NA	NA
Illinois	Yes	Any health insurer	Any denial of service based on lack of medical necessity, denials of specific tests, procedures, referrals to specialist physicians or hospitalization and length of stay requests.	Within 30 days of final notice of denial by the HMO.	$0	The State Insurance Commissioner.
Indiana	Yes	Any HMO	Denials of service based on medical necessity, experimental or investigational status of the treatment or any denial of a covered service.	Within 45 days of final notice of denial by the plan.	$25	The State Insurance Commissioner.
Iowa	Yes	Any health insurer	Any denial of covered benefits.	Within 60 days of final notice of coverage denial by the plan.	$25	The State Insurance Commissioner.
Kansas	Yes	Any health plan	Any denial of service	Within 90 days of final notice of denial by the plan.	$0	The State Insurance Commissioner.
Kentucky	Yes	Any health insurer	Any denial of service	Within 60 days of final notice of denial by the plan.	$25	The Independent External Review Program.
Louisiana	Yes	Any health insurer	Any denial of service	Within 60 days of final notice of denial by the plan	$0	The Medical Necessity Review Organization.
Maine	Yes	Any health insurer	Any denial of treatment	Within 12 months of final notice of denial by a health plan	No filing fee maybe requsted	The Bureau of Insurance.
Maryland	Yes	Any health insurer	Any denial of service	Within 30 days of notice of the denial by the health plan	$0	The State Insurance Commissioner.
Massachusetts	Yes	Any health plan	Any denial of service	45 days	$25	Office of Patient Protection.
Michigan	Yes	Any health carrier	Any denial of a covered benefits	Within 60 days of receipt of notice of the final denial by the health carrier.	$0	The State Insurance Commissioner.
Minnesota	Yes	Any health plan regulated by the insurance commissioner of the state	Any adverse determination	May be established by the health insurer and communicated to the insured.	$25	The Commissioner of Health.
Mississippi	No	NA	NA	NA	NA	NA
Missouri	Yes	Any health carrier	Any denial of covered services	Within 30 days of final agency decision concerning the second level review.	$0	The Director of the Department of Insurance.
Montana	Yes	Any health carrier or managed care entity	Any adverse determination	None	$0	The Montana Department of Insurance.
Nebraska	No	NA	NA	NA	NA	NA
Nevada	Yes	Any managed care organization	Any adverse determination.	Within 60 days of receiving notice of final adverse determination.	Can not exceed cost of issuing or renewing a certificate	Governors Office for Consumer Health Assistance. 1
New Hampshire	Yes	Any health carrier	Any adverse determination.	Within 180 days of the health carrier's second level denial.	$0	The Commissioner of Insurance. 2
New Jersey	Yes	Any health carrier	Any decision to deny, reduce or terminate a benefit.	Within 60 days of the date the final decision was issued.	$25	Independent Healthcare Appeals Program.
New Mexico	Yes	Any managed health care plan	Any decisions to deny, reduce or terminate covered services.	Within 30 days of notice of stage two internal review panel denial.	$0	The Department of Insurance.
New York	Yes	Any health care service plan	Any adverse determination	45 days	Up to $50	The Insurance Commissioner.
North Carolina	Yes	Any health insurer	Any benefit denial (noncertification decision), appeal decision supporting the benefit denial, or second level grievance decision supporting a benefit denial.	Within 60 days after the date of receipt of a notice of noncertification.	$0	The Department of Insurance.
North Dakota	No	NA	NA	NA	NA	NA
Ohio	Yes	Any health insuring corporation	Any decision to deny, reduce or terminate coverage when the service has been deemed not medically necessary.	Within 60 days of notice by the insured.	$0	The Superintendent of Insurance. 1
Oklahoma	Yes	Any health benefit plan.	For any denial based on a determination that the service or treatment is not medically necessary or appropriate.	Within 30 days of the notification of denial.	$50	The Department of Health. 3
Oregon	Yes	Any carrier or organized delivery system	Denials in whole or in part based on medical necessity.	Within 180 days of receipt of the coverage decision.	$0	The Commissioner of Insurance.
Pennsylvania	Yes	Any managed care plan	Any denial for covered services in the internal grievance process	Within 15 days of notification by the plan that the internal grievance has been denied.	Not more than $25.	The Department of Health of the Commonwealth.
Rhode Island	Yes	Decisions made by a review agen	Any denial for covered service based on a decision that the service was not medically necessary	None	$0	The Director of Health.
South Carolina	Yes	Any health carrier	Any adverse determination that has exhausted the internal appeals process.	Within 60 days of receipt of notice of denial.	$0	The Director of the Department of Insurance. 1
South Dakota	No	NA	NA	NA	NA	NA
Tennessee	Yes	Any HMO	Any denial based on a determination that the service was not medically necessary, the service was considered investigational or experimental and the requested service was covered under the plan.	Within 60 days of notification by the plan.	$50	The Insurance Commissioner. 1
Texas	Yes	Any HMO	Any adverse utilization review decision.	None	$0	The Department of Insurance.
Utah	Yes	Any health plan	Any denial of coverage	None	$0	The Commissioner of Insurance.
Vermont	Yes	Any health plan	Any decision to deny, reduce or terminate health care services.	None	$25	The Commissioner of Banking, Insurance, Securities, and Health Care Administration. 4
Virginia	Yes	Any health plan	Any utilization review denial of services.	None	$50. May be waived if it poses undue financial burden.	The Bureau of Insurance. 5
Washington	Yes	Any health carrier	Any decision to deny, modify, reduce or terminate coverage for health care service.	None	$0	The Commissioner of Insurance.
West Virginia	Yes	Any managed care plan	Any denial for services deemed not medically necessary or if the treatment if excluded as experimental.	Within 60 days of denial.	$0	Insurance Commissioner. 3
Wisconsin	Yes	Any health plan	Any denial based on a determination that the service requested was experimental, an admission to or continuation of a health facility stay, or on the determination that the services were not medically necessary.	None	$25	The Commissioner of Insurance. 6
Wyoming	No	NA	NA	NA	NA	NA

(show/hide notes)

Notes:	Data as of February 29, 2008.
Sources:	Health Policy Tracking Service, a service of Thomson West, available at http://www.netscan.com.
Definitions:	Independent/External Review: Measures that pertain to the independent review of adverse health benefit determinations appealed to a state authority or certified organization. NA: Not applicable
Footnotes:	Other Requirements: Minimum loss $500. Other Requirements: Minimum loss $400. Other Requirements: Minimum loss $1000. Other Requirements: Minimum loss $100. Other Requirements: Minimum loss $300. Other Requirements: Minimum loss $250.

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