Do consumers have the right to receive a copy of a health insurers medical criteria for approving a medical procedure?
A. Yes, Section 3077 E of Title 22 states, “A written notification of an adverse determination shall include the principal reason or reasons for the determination, the instructions for initiating an appeal or reconsideration of the determination, and the instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination.” Q. How long can an insurance company keep a claim in review? We have a patient that is in critical condition and is requiring surgery and the claim has been in review for four months. Is there a law that addresses this problem? A. If the member’s plan is a fully insured product and the issue is whether a procedure is medically necessary or not, then the carrier should make this determination within 30 days of receiving the necessary information. Please see LRS 22:3070 for additional information or file a complaint with this office for assistance. Q. As a contracted group of physicians and pe
