What happens if the denial is upheld on external appeal?
The reviewing entity supplies the reasons and rationale for its recommendation to the Commissioner of Insurance, or his designee. The Commissioner or designee reviews the recommendation to ensure that it is not arbitrary or capricious. The Commissioner or designee then issues a written ruling which either upholds, reverses or modifies the MCHIP’s final adverse decision. The written ruling is binding on both the MCHIP member and the MCHIP to the same extent to which each would have been bound by a judgment entered in an action at law or in equity with respect to the issues which the impartial external entity examined in its review.
