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3. The covered person has exhausted the health carrier's internal grievanceprocess or filed an expedited external review request; and4. The covered person has provided all the information and forms required toprocess a standard or expedited external review. If the service or treatment isexperimental or investigational, the health carrier must also determine whether:• the requested health care treatment that is the subject of thedetermination (a) is a covered benefit under the enrollee's health benefitplan except for the health carrier's determination that the service ortreatment is experimental or investigational and (b) is not explicitlyexcluded under the enrollee's health benefit plan;• the enrollee's treating health care professional has certified that (a)standard health care treatments have not been effective in improving thecovered person's medical condition, (b) standard health care treatmentsare not medically appropriate for the person, or (c) there is no availablestandard health care treatment covered by the health carrier that is morebeneficial than the requested health care treatment; and• the enrollee's treating health care professional (a) has recommended ahealth care treatment that he or she certifies, in writing, is likely to bemore beneficial to the enrollee than any available standard health caretreatments or (b) is a licensed, board certified, or board eligible healthcare professional qualified to practice in the area of medicine appropriateto treat the enrollee's condition and has certified, in writing, thatscientifically valid studies using accepted protocols demonstrate that thehealth care treatment the covered person requested is likely to be morebeneficial than any available standard health care treatments.Oxford must notify the Commissioner and the enrollee in writing on whether the requestis complete and eligible for external review within one business day after completing thepreliminary review for a standard external review request or on the day the preliminaryreport is completed for an expedited external review request. The Commissioner mayspecify the form for the health carrier's initial determination notice.If the request is not complete, Oxford's notice must specify the information needed toperfect the request. If the request is not eligible for standard or expedited external review,the notice must include the reasons for its ineligibility.The notice must include a statement informing the enrollee that he or she can appeal thisdetermination to the Commissioner. Regardless of a health carrier's initial determinationthat a request for a standard or expedited external review is ineligible for review, theCommissioner may determine, pursuant to the terms of the enrollee's health benefit plan,that the request is eligible and assign an independent review organization to conduct it.Within one business day, for a standard external review request, or one calendar day, foran expedited external review request, of receiving notice that a request is eligible forreview, the State of Connecticut Insurance Commissioner must (1) assign anindependent review organization to conduct the review (randomly from among qualifiedorganizations), (2) notify the health carrier of the organization's name, and (3) notify theenrollee in writing of the eligibility and acceptance for review. The written notice mustinclude (1) a statement that the enrollee may submit, within five business days afterreceiving the notice, additional information in writing to the organization for considerationand (2) where and how such additional information must be submitted. If additionalinformation is submitted later than five business days after the covered person receivedthe notice, the organization may, but is not be required to, accept and consider it.Health Carrier - Providing InformationWithin five business days for a standard external review and one calendar day for anexpedited external review after receiving the name of the assigned independent review10Utilization Management Appeal Process and Timeframes for Connecticut Plans: Administrative Policy(Effective 06/11/2013)©1996-2013, Oxford Health Plans, LLC
organization, Oxford must provide the organization any information it considered inmaking the determination under review.If Oxford fails to timely provide the information, the organization (1) must not delayperforming the review and (2) may terminate the review and make a decision to reversethe determination. Within one business day after terminating the review and deciding toreverse the determination, the organization must notify the commissioner, Oxford, andenrollee in writing.Independent Review Organization - Receipt of New InformationThe organization must review all the information received from the enrollee and Oxford.In reaching a decision, the organization is not bound by any decisions reached during theOxford's utilization review process. Upon receiving any new information from the coveredperson, the organization has one business day to forward it to the health carrier.If the enrollee submits new information, Oxford will have the opportunity to review theinformation and reconsider the original decision. This reconsideration will not delay theexternal review. However, if Oxford decides to reverse its original denial, Oxford has 1business day to notify the Commissioner, independent review organization and theenrollee of the reversal. At this point, the external review will be terminated.Oxford shall provide continued coverage of an ongoing course of treatment pending theoutcome of the Stage 3 External appeal.Decision timeframe: The external review agent will render a decision for standardexternal reviews, 45 days; standard external reviews involving an experimental orinvestigational treatment or service, 20 days; expedited external reviews, 72 hours; andexpedited external reviews involving an experimental or investigational treatment orservice, five days.oFor Rhode Island residents who are Members of Connecticut plans and havechosen to utilize the State of Rhode Island external appeal process, decisionsfrom the external reviewer must be made within 10 business days of the requestfor standard external appeals and within 2 business days of the request forexpedited external appeals. This is the final decision for all CommercialMembers.REFERENCESC.G.S.A. § 38a-226c and §38a-478n.Regulations of the Connecticut State Agencies Sections 38a-226c-1 et seq. and 38a-487n-3-2 etseq.General Laws of Rhode Island Annotated §23-17.12-10.Rhode Island Department of Health Rules and Regulations for the Utilization Review of HealthCare Services (R23-17.12-UR).NCQA Guidelines.Department of Labor Regulations 29 CFR 2560.503.1.CT Public Act 11-58Utilization Management Appeal Process and Timeframes for Connecticut Plans: Administrative Policy(Effective 06/11/2013)11©1996-2013, Oxford Health Plans, LLC
Page 3 and 4: Pre-certification (urgent): A reque
Page 5 and 6: • Levels of Appeal: Participating
Page 7 and 8: ooA statement disclosing the Member
Page 9: • A statement disclosing the Memb

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