44-5436.

Adverse determinations; appeals; review by physician.

A utilization review agent shall ensure that all appeals of an adverse determination for prior authorization are reviewed by a physician. Such physician shall:

(1) Possess a current and valid unrestricted license in a United States jurisdiction;

(2) Be of the same or similar specialty as the ordering physician or have the training and experience to treat the condition, which means that either:

(a) The physician maintains board certification for the same or similar specialty; or

(b) The physician's training and experience (i) includes treating the condition, (ii) includes treating complications that may result from the health care service, and (iii) is sufficient for the physician to determine based on the physician's clinical judgment whether the health care service is medically necessary or clinically appropriate;

(3) Not have been directly involved in making the initial 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 agent by the enrollee's health care provider, or a health care facility, and any pertinent medical literature provided to the utilization review agent by the health care provider.