Question
Are all types of internal appeals eligible for external review?
Yes Answer
Incorrect!
Denials based on medical decision-making are eligible for external review, specifically:
- A determination that a covered health care service does not meet the insurer’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness; or
- A denial for the reason that a treatment is experimental or investigational.
No Answer
Correct!
Denials based on medical decision-making are eligible for external review, specifically:
- A determination that a covered health care service does not meet the insurer’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness; or
- A denial for the reason that a treatment is experimental or investigational.
