determinations. A. A contracted entity shall utilize uniform procedures established by the Authority under subsection B of this section for the review and appeal of any adverse determination by the contracted entity sought by any member or provider adversely affected by such determination. B. The Authority shall develop procedures for members or providers to seek review by the contracted entity of any adverse determination made by the contracted entity. C. A provider shall have six (6) months from the receipt of a claim denial to file an appeal. D. A contracted entity shall ensure that all appeals of adverse determinations made by the contracted entity are reviewed by a licensed physician or, if appropriate for the requested service, a licensed mental health professional. The contracted entity shall not use any automated claim review software or other automated functionality for such appeals. E. The physician or mental health professional who reviews the appeal 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 or mental health professional who typically manages the medical condition or disease. This requirement shall be considered met: a. for a physician, if: (1) the physician maintains board certification for the same or similar specialty as the medical condition in question, or (2) the physician’s training and experience: (a) includes treatment of the condition, (b) includes treatment of complications that may result from the service or procedure, and (c) is sufficient for the physician to determine if the service or procedure is medically necessary or clinically appropriate, or b. for a mental health professional, if the mental health professional’s training and experience: (1) includes treatment of the condition, and (2) is sufficient for the mental health professional to determine if the service is medically necessary or clinically appropriate; 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 any medical records pertinent to the active condition that are provided to the contracted entity by the member’s provider, or a health care facility, and any pertinent medical literature provided to the contracted entity by the provider. F. Upon receipt of notice from the contracted entity that the adverse determination has been upheld on appeal, the member or provider may request a fair hearing from the Authority. The Authority shall develop procedures for fair hearings in accordance with 42 C.F.R., Part 431.
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