Idaho Health Carrier External Review Act Overview

What is the purpose of the Idaho Health Carrier External Review Act?

To establish uniform standards for external review procedures

Which types of plans are exempt from the provisions of the Idaho Health Carrier External Review Act?

Medicare Advantage plans

When does the health carrier have to notify the covered person about their right to request an external review?

When a final adverse benefit determination is made

Which of the following types of coverage are expressly not subject to the Idaho Health Carrier External Review Act?

Dental insurance Signup and view all the answers

What should be included in the notice to a covered person regarding their right to request an external review?

'We have denied your request for a health care service.' Signup and view all the answers

Which of the following plans are not subject to the Idaho Health Carrier External Review Act?

Plans covering vision care Signup and view all the answers

What documents will the independent review organization consider in reaching a decision?

Consulting reports from appropriate health care professionals and other documents submitted by the health carrier or the covered person Signup and view all the answers

What must the independent review organization decide within 72 hours of receiving a request for an expedited external review?

To uphold or reverse the final adverse benefit determination Signup and view all the answers

What is required for an independent review organization to be approved for conducting external reviews?

Having accreditation standards that are equivalent to or exceed the minimum qualifications established under Idaho code Signup and view all the answers

Who needs to be notified of the decision made by the independent review organization after conducting an external review?

The covered person, the health carrier, and the director Signup and view all the answers

What must an independent review organization do upon request regarding external reviews conducted during a calendar year?

Maintain written records and submit a report to the director Signup and view all the answers

Which guideline is NOT mentioned as part of what the independent review organization considers in reaching a decision?

The treating provider's personal experience Signup and view all the answers

When can a covered person request an external review?

Only after exhausting the health carrier's internal grievance process Signup and view all the answers

What does the health carrier need to determine during a preliminary review of an external review request?

If the covered person was enrolled in the health benefit plan at the time of service Signup and view all the answers

Under what circumstances can a covered person be considered to have exhausted the health carrier's internal grievance process?

After receiving a written decision from the health carrier within 35 days Signup and view all the answers

When must the health carrier notify the director and covered person about the request for external review?

Within 5 business days after completing a preliminary review Signup and view all the answers

In what situation can a covered person request an expedited external review?

Only for urgent care service requests that meet specific criteria Signup and view all the answers

What is one of the conditions that must be met for a health carrier to complete a preliminary review of an external review request?

The covered person has provided all required information for processing Signup and view all the answers

What must be included in a request for an external review to be considered complete?

The release form and all required information Signup and view all the answers