(a) (1) A healthcare provider has a right to a review of an adverse determination regarding a prior authorization exemption within twelve (12) months of receiving proper notice of recission from a healthcare insurer to be conducted by an independent review organization. (2) A healthcare insurer shall not require a healthcare provider to engage in an internal appeal process before requesting a review by an independent review organization under this section. (3) A healthcare provider who has an exemption rescinded due to a failure to provide medical records within sixty (60) days of a record request for a retrospective review shall not be eligible for review of that rescission by an independent review entity. (b) A healthcare insurer shall pay: (1) For any appeal or independent review of an adverse determination regarding a prior authorization exemption requested under this section; and (2) A reasonable fee determined by the Arkansas State Medical Board for any copies of medical records or other documents requested from a healthcare provider during an exemption rescission review requested under this section. (c) An independent review organization shall complete an expedited review of an adverse determination regarding a prior authorization exemption no later than the thirtieth day after the date a healthcare provider files the request for a review under this section. (d) (1) A healthcare provider may request that the independent review organization consider another random sample of no fewer than five (5) and no more than twenty (20) claims submitted to the healthcare insurer by the healthcare provider during the relevant evaluation period for the relevant healthcare service as part of the review under this section. (2) If a healthcare provider makes a request under subdivision (d)(1) of this section, the independent review organization shall base its determination on the medical necessity of claims reviewed: (A) By the healthcare insurer under § 23-99-1122 ; and (B) By the independent review organization under subdivision (d)(1) of this section. (e) The Insurance Commissioner may refuse, suspend, revoke, or not renew a license or certificate of authority of a healthcare insurer that has fifty percent (50%) of healthcare provider appeals overturned in a twelve-month period by an independent review organization under this section. Added by Act 2023, No. 575,§ 5, eff. 8/1/2023. (a) (1) A healthcare provider has a right to a review of an adverse determination regarding a prior authorization exemption within twelve (12) months of receiving proper notice of recission from a healthcare insurer to be conducted by an independent review organization. (2) A healthcare insurer shall not require a healthcare provider to engage in an internal appeal process before requesting a review by an independent review organization under this section. (3) A healthcare provider who has an exemption rescinded due to a failure to provide medical records within sixty (60) days of a record request for a retrospective review shall not be eligible for review of that rescission by an independent review entity. (b) A healthcare insurer shall pay: (1) For any appeal or independent review of an adverse determination regarding a prior authorization exemption requested under this section; and (2) A reasonable fee determined by the Arkansas State Medical Board for any copies of medical records or other documents requested from a healthcare provider during an exemption rescission review requested under this section. (c) An independent review organization shall complete an expedited review of an adverse determination regarding a prior authorization exemption no later than the thirtieth day after the date a healthcare provider files the request for a review under this section. (d) (1) A healthcare provider may request that the independent review organization consider another random sample of no fewer than five (5) and no more than twenty (20) claims submitted to the healthcare insurer by the healthcare provider during the relevant evaluation period for the relevant healthcare service as part of the review under this section. (2) If a healthcare provider makes a request under subdivision (d)(1) of this section, the independent review organization shall base its determination on the medical necessity of claims reviewed: (A) By the healthcare insurer under § 23-99-1122 ; and (B) By the independent review organization under subdivision (d)(1) of this section. (e) The Insurance Commissioner may refuse, suspend, revoke, or not renew a license or certificate of authority of a healthcare insurer that has fifty percent (50%) of healthcare provider appeals overturned in a twelve-month period by an independent review organization under this section. Added by Act 2023, No. 575,§ 5, eff. 8/1/2023. (a) (1) A healthcare provider has a right to a review of an adverse determination regarding a prior authorization exemption within twelve (12) months of receiving proper notice of recission from a healthcare insurer to be conducted by an independent review organization. (2) A healthcare insurer shall not require a healthcare provider to engage in an internal appeal process before requesting a review by an independent review organization under this section. (3) A healthcare provider who has an exemption rescinded due to a failure to provide medical records within sixty (60) days of a record request for a retrospective review shall not be eligible for review of that rescission by an independent review entity. (b) A healthcare insurer shall pay: (1) For any appeal or independent review of an adverse determination regarding a prior authorization exemption requested under this section; and (2) A reasonable fee determined by the Arkansas State Medical Board for any copies of medical records or other documents requested from a healthcare provider during an exemption rescission review requested under this section. (c) An independent review organization shall complete an expedited review of an adverse determination regarding a prior authorization exemption no later than the thirtieth day after the date a healthcare provider files the request for a review under this section. (d) (1) A healthcare provider may request that the independent review organization consider another random sample of no fewer than five (5) and no more than twenty (20) claims submitted to the healthcare insurer by the healthcare provider during the relevant evaluation period for the relevant healthcare service as part of the review under this section. (2) If a healthcare provider makes a request under subdivision (d)(1) of this section, the independent review organization shall base its determination on the medical necessity of claims reviewed: (A) By the healthcare insurer under § 23-99-1122 ; and (B) By the independent review organization under subdivision (d)(1) of this section. (e) The Insurance Commissioner may refuse, suspend, revoke, or not renew a license or certificate of authority of a healthcare insurer that has fifty percent (50%) of healthcare provider appeals overturned in a twelve-month period by an independent review organization under this section. Added by Act 2023, No. 575,§ 5, eff. 8/1/2023. (a) (1) A healthcare provider has a right to a review of an adverse determination regarding a prior authorization exemption within twelve (12) months of receiving proper notice of recission from a healthcare insurer to be conducted by an independent review organization. (2) A healthcare insurer shall not require a healthcare provider to engage in an internal appeal process before requesting a review by an independent review organization under this section. (3) A healthcare provider who has an exemption rescinded due to a failure to provide medical records within sixty (60) days of a record request for a retrospective review shall not be eligible for review of that rescission by an independent review entity. (1) A healthcare provider has a right to a review of an adverse determination regarding a prior authorization exemption within twelve (12) months of receiving proper notice of recission from a healthcare insurer to be conducted by an independent review organization. (2) A healthcare insurer shall not require a healthcare provider to engage in an internal appeal process before requesting a review by an independent review organization under this section. (3) A healthcare provider who has an exemption rescinded due to a failure to provide medical records within sixty (60) days of a record request for a retrospective review shall not be eligible for review of that rescission by an independent review entity. (b) A healthcare insurer shall pay: (1) For any appeal or independent review of an adverse determination regarding a prior authorization exemption requested under this section; and (2) A reasonable fee determined by the Arkansas State Medical Board for any copies of medical records or other documents requested from a healthcare provider during an exemption rescission review requested under this section. (1) For any appeal or independent review of an adverse determination regarding a prior authorization exemption requested under this section; and (2) A reasonable fee determined by the Arkansas State Medical Board for any copies of medical records or other documents requested from a healthcare provider during an exemption rescission review requested under this section. (c) An independent review organization shall complete an expedited review of an adverse determination regarding a prior authorization exemption no later than the thirtieth day after the date a healthcare provider files the request for a review under this section. (d) (1) A healthcare provider may request that the independent review organization consider another random sample of no fewer than five (5) and no more than twenty (20) claims submitted to the healthcare insurer by the healthcare provider during the relevant evaluation period for the relevant healthcare service as part of the review under this section. (2) If a healthcare provider makes a request under subdivision (d)(1) of this section, the independent review organization shall base its determination on the medical necessity of claims reviewed: (A) By the healthcare insurer under § 23-99-1122 ; and (B) By the independent review organization under subdivision (d)(1) of this section. (1) A healthcare provider may request that the independent review organization consider another random sample of no fewer than five (5) and no more than twenty (20) claims submitted to the healthcare insurer by the healthcare provider during the relevant evaluation period for the relevant healthcare service as part of the review under this section. (2) If a healthcare provider makes a request under subdivision (d)(1) of this section, the independent review organization shall base its determination on the medical necessity of claims reviewed: (A) By the healthcare insurer under § 23-99-1122 ; and (B) By the independent review organization under subdivision (d)(1) of this section. (A) By the healthcare insurer under § 23-99-1122 ; and (B) By the independent review organization under subdivision (d)(1) of this section. (e) The Insurance Commissioner may refuse, suspend, revoke, or not renew a license or certificate of authority of a healthcare insurer that has fifty percent (50%) of healthcare provider appeals overturned in a twelve-month period by an independent review organization under this section.
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