376.1365. Reconsideration of an adverse determination, when.
Reconsideration of an adverse determination, when.
376.1365. 1. In a case involving an initial determination or aconcurrent review determination, a health carrier shall give the providerrendering the service an opportunity to request on behalf of the enrollee areconsideration of an adverse determination by the reviewer making theadverse determination.
2. The reconsideration shall occur within one working day of thereceipt of the request and shall be conducted between the providerrendering the service and the reviewer who made the adverse determinationor a clinical peer designated by the reviewer if the reviewer who made theadverse determination is not available within one working day.
3. If the reconsideration process does not resolve the difference ofopinion, the adverse determination may be appealed by the enrollee or theprovider on behalf of the enrollee. Reconsideration is not a prerequisiteto a standard appeal or an expedited appeal of an adverse determination.
(L. 1997 H.B. 335)