AN ACT relative to external review under the managed care law.

SPONSORS: Sen. White, Dist 9; Sen. Houde, Dist 5; Rep. Hunt, Ches 7; Rep. Schlachman, Rock 13; Rep. Flanders, Belk 4; Rep. Headd, Rock 3



This bill clarifies the external review process for the purposes of the managed care law.

This bill is a request of the insurance department.

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Explanation: Matter added to current law appears in bold italics.

Matter removed from current law appears [in brackets and struckthrough.]

Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.




In the Year of Our Lord Two Thousand Twelve

AN ACT relative to external review under the managed care law.

Be it Enacted by the Senate and House of Representatives in General Court convened:

98:1 Right to External Review. Amend RSA 420-J:5-a, I(d)-(f) to read as follows:

(d) [The covered person’s cost for the service, supply or drug that is the subject of the adverse determination is, or is anticipated in a 12-month period to be, equal to or in excess of $400;

(e)] The health carrier determination does not relate to any category of health care services that is excluded from the external review provisions of this chapter pursuant to paragraph II; and

[(f)] (e) The request for external review is not based on a claim or allegation of provider malpractice, professional negligence, or other professional fault excluded from the external review provisions of this chapter pursuant to paragraph III.

98:2 Managed Care Law; Expedited External Review. Amend RSA 420-J:5-c, II to read as follows:

II. Except to the extent that it is inconsistent with the provisions of this paragraph, all requirements for the conduct of standard external review specified in RSA 420-J:5-b shall apply to expedited external review. However, a person who meets the standard set forth in paragraph I for expedited external review, as well as the reviewability requirements set forth in RSA 420-J:5-b, I, may pursue expedited external review simultaneous with the internal review process in RSA 420-J:5.

98:3 Managed Care Law; Certification of Independent Review Organizations. Amend RSA 420-J:5-d, II(g)-(h) to read as follows:

(g) It shall be accredited by a nationally recognized accreditation organization to perform external reviews.

(h) For the purpose of allowing in-state health care providers to act as clinical peer reviewers in the conduct of external reviews, the commissioner may determine, in specific cases, that an affiliation with a hospital, an institution, an academic medical center, or a health carrier provider network does not in and of itself constitute a conflict of interest which is sufficient to preclude that provider from acting as a clinical peer reviewer, so long as the affiliation is disclosed to the covered person or the covered person’s authorized representative.

[(h)] (i) The following organizations shall not be eligible for certification to conduct external reviews:

(1) Professional or trade associations of health care providers;

(2) Subsidiaries or affiliates of such provider associations;

(3) Health carrier or health plan associations; and

(4) Subsidiaries or affiliates of health plan or health carrier associations.

98:4 Effective Date. This act shall take effect 60 days after its passage.

Approved: May 29, 2012

Effective Date: July 28, 2012