A utilization review entity shall ensure that all appeals are reviewed by a physician, pharmacist, or licensed mental health professional. The physician, pharmacist, or licensed mental health professional shall: 1. Possess a current and valid unrestricted license in any United States jurisdiction; 2. Be of the same or similar specialty as a physician, pharmacist, or licensed mental health professional who typically manages the medical condition or disease, which means that the physician either maintains board certification for the same or similar specialty as the medical condition in question or whose training and experience: a. includes treating the condition, b. includes treating complications that may result from the service or procedure, and c. is sufficient for the physician, pharmacist, or licensed mental health professional to determine if the service or procedure is medically necessary or clinically appropriate, except for appeals coming from a licensed mental health professional, which may be conducted by another licensed mental health professional as opposed to a physician, or for appeals coming from a pharmacist, which may be conducted by another licensed pharmacist as opposed to a physician; 3. Not have been directly involved in making the adverse determination; 4. Not have any financial interest in the outcome of the appeal; and 5. Consider all known clinical aspects of the health care service under review, including, but not limited to, a review of those medical records which are pertinent and relevant to the active condition provided to the utilization review entity by the enrollee's health care provider, or a health care facility, and any pertinent medical literature provided to the utilization review entity by the health care provider.
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