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Current Status Bill Number:View additional legislative information at the LPITS web site.5267 Type of Legislation:General Bill GB Introducing Body:House Introduced Date:20020514 Primary Sponsor:Sinclair All Sponsors:Sinclair, Talley, R. Brown, Coleman, Merrill, Rivers, Sheheen, W.D. Smith and Weeks Drafted Document Number:l:\council\bills\nbd\11582ac02.doc Residing Body:House Current Committee:Labor, Commerce and Industry Committee 26 HLCI Subject:Health insurance coverage, provisions regarding insured's request for external review of denial of coverage History Body Date Action Description Com Leg Involved ______ ________ ______________________________________ _______ ____________ House 20020514 Introduced, read first time, 26 HLCI referred to Committee Versions of This Bill
TO AMEND SECTION 38-71-1940, CODE OF LAWS OF SOUTH CAROLINA, 1976, RELATING TO THE REQUIREMENT THAT A HEALTH INSURANCE CARRIER PROVIDE NOTICE TO AN INSURED ON THE RIGHT TO REQUEST AN EXTERNAL REVIEW OF A DENIAL OF COVERAGE, SO AS TO PROVIDE THAT AN ADVERSE DETERMINATION INCLUDES DENIAL OF COVERAGE BASED ON MEDICAL NECESSITY OR OTHER CLINICAL DECISIONS; TO AMEND SECTION 38-71-1960, RELATING TO THE REQUIREMENT THAT AN INSURED EXHAUST THE HEALTH CARRIER'S INTERNAL APPEAL PROCESS BEFORE SEEKING AN EXTERNAL REVIEW, SO AS TO REQUIRE THE CARRIER TO SUBMIT ITS INTERNAL APPEAL PROCEDURES AND THE TIME PERIODS WITHIN WHICH THE APPEAL MUST BE CONDUCTED AND COMPLETED TO THE DEPARTMENT OF INSURANCE FOR APPROVAL; TO AMEND SECTION 38-71-1970, RELATING TO REQUESTS FOR EXTERNAL REVIEW, SO AS TO CLARIFY THAT FAILURE BY A HEALTH CARRIER TO PROVIDE DOCUMENTS TO THE INDEPENDENT REVIEW ORGANIZATION MAY NOT DELAY THE EXTERNAL REVIEW AND TO FURTHER CLARIFY THAT IN CONVENING THE EXTERNAL REVIEW PANEL, THE HEALTH CARRIER MAY REQUEST, RATHER THAN REQUIRE, A CERTAIN NUMBER OF HEALTH PROFESSIONALS BE SEATED ON THE PANEL; AND TO AMEND SECTION 38-71-1980, AS AMENDED, RELATING TO EXPEDITED EXTERNAL REVIEW, SO AS TO CLARIFY PROCEDURES RESULTING FROM A HEALTH CARRIER FAILING TO PROVIDE DOCUMENTS WITHIN THE REQUIRED TIME PERIODS.
Be it enacted by the General Assembly of the State of South Carolina:
SECTION 1. Section 38-71-1940(B)(1) of the 1976 Code is amended to read:
"(1) The health carrier shall include in the notice required under subsection (A) a clear and concise description of the right of the covered person to request a standard external review pursuant to Section 38-71-1970 or an expedited external review pursuant to Section 38-71-1980 upon receipt of an adverse determination or a final adverse determination, including denial of coverage is based, in whole or in part, on a medical necessity or other clinical decision, and the circumstances under which the covered person is not required to exhaust the health carrier's internal appeal process or is considered to have exhausted the health carrier's internal appeal process pursuant to Section 38-71-1960."
SECTION 2. Section 38-71-1960 of the 1976 Code is amended by adding at the end:
"(D) A health carrier's internal appeal process, procedures, and time periods, including the time within which the process must be completed, must be submitted to and approved by the department."
SECTION 3. Section 38-71-1970(B)(2) of the 1976 Code is amended to read:
"(2) Except as provided in subsection (B)(3), Failure by the health carrier or its designee to send the documents and information within the time specified in subsection (B)(1) may not delay the conduct of the external review."
SECTION 4. Section 38-71-1970(D)(3)(b)(ii) of the 1976 Code is amended to read:
"(ii) The health carrier may require request that the panel consist of at least three physicians or other health care professionals who meet the minimum qualifications described in Section 38-71-2010 and, through clinical experience in the past three years, are experts in the treatment of the covered person's condition and knowledgeable about the recommended or requested health care service or treatment."
SECTION 5. Section 38-71-1980(B)(2) of the 1976 Code is amended to read:
"(2) Except as provided in subsection (B)(3), Failure by the health carrier or its designee to send the documents and information within the time specified in subsection (B)(1) may not delay the conduct of the external review."
SECTION 6. This act takes effect upon approval by the Governor.
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