9517

(a)\n(1) Each health insurance organization or issuer shall include a description of the external review procedures in the policy, certificate, membership booklet, outline of coverage. or other evidence of coverage it provides to covered persons or enrollees.\n(2) The disclosure of external review procedures required by clause (1) of this subsection shall be in a format prescribed by the Commissioner.\n(b) The description of external review procedures shall include a statement that informs the covered person or enrollee of his/her right to file a request for an external review of an adverse determination or final adverse determination with the Commissioner. The statement may explain that external review is available when the adverse determination or final adverse determination involves an issue of medical necessity, appropriateness, healthcare setting, level of care, or effectiveness of service or rescission of coverage. The statement shall include the telephone number and address of the Commissioner.\n(c) In addition to the provisions of subsection (b) of this Section, the statement shall inform the covered person or enrollee that, when filing a request for an external review,

f the Commissioner.\n(c) In addition to the provisions of subsection (b) of this Section, the statement shall inform the covered person or enrollee that, when filing a request for an external review, he/she will be required to authorize the release of any medical information that may be required or necessary to be reviewed for the purpose of reaching a decision on the external review.\nHistory —Aug. 29, 2011, No. 194, added as § 28.180 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.