Health Carrier External Review Model Act

What this document is

Health Carrier External Review Model Act is a naic model law published by National Association of Insurance Commissioners (NAIC). It is one of the documents that insurance license exam questions are written from, including life & health practice questions. This page summarizes it and points to the official version, which is the text to rely on.

Sections cited in practice questions

Each practice answer shows the exact passage it comes from. These are sections of this document that questions cite, with a short excerpt from the source text.

• NAIC Model NAIC 075: Section 11C (Binding Nature of External Review Decision)

  “A covered person or the covered person’s authorized representative may not file a subsequent request for external review involving the same adverse determination or final adverse determination for which the covered person has already received an external review decision pursuant to this Act.”

• NAIC Uniform Health Carrier External Review Model Act § 9 (Expedited External Review: retrospective determinations excluded)

  “An expedited external review may not be provided for retrospective adverse or final adverse determinations.”

• NAIC Uniform Health Carrier External Review Model Act § 9C (Expedited External Review: independent review organization not bound)

  “In reaching a recommendation, the assigned independent review organization is not bound by any decisions or conclusions reached during the health carrier’s utilization review process as set forth in [insert reference to state law equivalent to the Utilization Review and Benefit Determination Model...”

• Health Carrier External Review Model Act, Section 10 Option 1, Subsection E(3)(b) (External Review of Experimental or Investigational Treatment Adverse Determinations)

  “(b) Neither the covered person, the covered person’s authorized representative, if applicable, nor the health carrier shall choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review.”

• Health Carrier External Review Model Act, Section 10 Option 1, Subsection K(2)(c) (External Review of Experimental or Investigational Treatment Adverse Determinations)

  “(c) (i) If the clinical peer reviewers are evenly split as to whether the recommended or requested health care service or treatment should be covered, the independent review organization shall obtain the opinion of an additional clinical peer reviewer in order for the independent review...”

• Health Carrier External Review Model Act, Section 13D (Approval of Independent Review Organizations)

  “D. (1) An approval is effective for two (2) years, unless the commissioner determines before expiration of the approval that the independent review organization is not satisfying the minimum qualifications established under Section 14 of this Act. (2) Whenever the commissioner determines that an...”

• Health Carrier External Review Model Act, Section 14B (Minimum Qualifications for Independent Review Organizations)

  “B. All clinical peer reviewers assigned by an independent review organization to conduct external reviews shall be physicians or other appropriate health care providers who meet the following minimum qualifications: (1) Be an expert in the treatment of the covered person’s medical condition that is...”

• Health Carrier External Review Model Act, Section 14D(1) (Minimum Qualifications for Independent Review Organizations)

  “D. (1) In addition to the requirements set forth in Subsections A, B and C, to be approved pursuant to Section 13 of this Act to conduct an external review of a specified case, neither the independent review organization selected to conduct the external review nor any clinical peer reviewer...”

• Health Carrier External Review Model Act, Section 15 (Hold Harmless for Independent Review Organizations)

  “No independent review organization or clinical peer reviewer working on behalf of an independent review organization shall be liable in damages to any person for any opinions rendered during or upon completion of an external review conducted pursuant to this Act, unless the opinion was rendered in...”

• Health Carrier External Review Model Act, Section 17 (Funding of External Review)

  “The health carrier against which a request for a standard external review or an expedited external review is filed shall pay the cost of the independent review organization for conducting the external review.”

• Health Carrier External Review Model Act, Section 3P (Definitions, final adverse determination)

  “P. “Final adverse determination” means an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review organization, at the completion of the health carrier’s internal grievance process procedures as set forth in [insert reference to...”

• Health Carrier External Review Model Act, Section 5B(2) (Notice of Right to External Review)

  “(2) In addition to the information to be provided pursuant to Paragraph (1), the health carrier shall include a copy of the description of both the standard and expedited external review procedures the health carrier is required to provide pursuant to Section 18 of this Act, highlighting the...”

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