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S.B. 164 VETOES
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(II) INCLUDE THE FOLLOWING INFORMATION:
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1. THAT THE MEMBER, OR A HEALTH CARE PROVIDER
ACTING ON BEHALF OF THE MEMBER, HAS A RIGHT TO FILE AN APPEAL WITH THE
CARRIER;
2. THAT THE MEMBER OR A HEALTH CARE PROVIDER
ACTING ON BEHALF OF THE MEMBER, MAY FILE A COMPLAINT WITH THE
COMMISSIONER WITHOUT FIRST FILING AN APPEAL, IF THE COVERAGE DECISION
INVOLVES AN URGENT MEDICAL CONDITION FOR WHICH CARE HAS NOT BEEN
RENDERED;
3. THE COMMISSIONER'S ADDRESS, TELEPHONE NUMBER
AND FACSIMILE NUMBER;
4. THAT THE HEALTH ADVOCACY UNIT IS AVAILABLE TO
ASSIST THE MEMBER IN BOTH MEDIATING AND FILING AN APPEAL UNDER THE
CARRIER'S INTERNAL APPEAL PROCESS; AND
5. THE ADDRESS, TELEPHONE NUMBER FACSIMILE
NUMBER AND EMAIL ADDRESS OF THE HEALTH ADVOCACY UNIT.
(F) (1) WITHIN 30 CALENDAR DAYS AFTER THE APPEAL DECISION HAS BEEN
MADE, EACH CARRIER SHALL SEND TO THE MEMBER AND THE HEALTH CARE
PROVIDER ACTING ON BEHALF OF THE MEMBER A WRITTEN NOTICE OF THE APPEAL
DECISION.
(2) NOTICE OF THE APPEAL DECISION REQUIRED TO BE SENT UNDER
PARAGRAPH (1) OF THE THIS SUBSECTION SHALL:
(I) STATE IN DETAIL IN CLEAR UNDERSTANDABLE LANGUAGE
THE SPECIFIC FACTUAL BASES FOR THE CARRIER'S DECISION; AND
(II) INCLUDE THE FOLLOWING INFORMATION:
1. THAT THE MEMBER, OR A HEALTH CARE PROVIDER
ACTING ON BEHALF OF THE MEMBER HAS A RIGHT TO FILE A COMPLAINT WITH THE
COMMISSIONER WITHIN 60 WORKING DAYS AFTER RECEIPT OF A CARRIER'S APPEAL
DECISION; AND
2. THE COMMISSIONER'S ADDRESS, TELEPHONE NUMBER,
AND FACSIMILE NUMBER.
(F) (G) THE COMMISSIONER MAY REQUEST THE MEMBER THAT FILED THE
COMPLAINT OR A LEGALLY AUTHORIZED DESIGNEE OF THE MEMBER TO SIGN A
CONSENT FORM AUTHORIZING THE RELEASE OF THE MEMBERS MEDICAL RECORDS
TO THE COMMISSIONER OR THE COMMISSIONER'S DESIGNEE THAT ARE NEEDED IN
ORDER FOR THE COMMISSIONER TO MAKE A FINAL DECISION ON THE COMPLAINT.
(G) (H) (1) DURING THE REVIEW OF A COMPLAINT BY THE COMMISSIONER
OR A DESIGNEE OF THE COMMISSIONER, A CARRIER SHALL HAVE THE BURDEN OF
PERSUASION THAT ITS COVERAGE DECISION OR APPEAL DECISION, AS APPLICABLE,
IS CORRECT.
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- 3738 -
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