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- Alaska Statutes.
- Title 21. Insurance
- Chapter 7. Regulation of Managed Care Insurance Plans
- Section 60. Qualifications of External Appeal Agencies.
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Section 50. External Health Care Appeals.
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Section 70. Limitation On Liability of Reviewers.
AS 21.07.060. Qualifications of External Appeal Agencies.
- (a) An external appeal agency qualifies to consider external appeals if, with respect to a managed care plan, the agency
is certified by a qualified private standard-setting organization approved by the director or by a health insurer
operating in this state as meeting the requirements imposed under (b) of this section.
- (b) An external appeal agency is qualified to consider appeals of managed care plan health care decisions if the agency
meets the following requirements:
- (1) the agency meets the independence requirements of this section;
- (2) the agency conducts external appeal activities through a panel of two clinical peers, unless otherwise agreed to by
both parties; and
- (3) the agency has sufficient medical, legal, and other expertise and sufficient staffing to conduct external appeal
activities for the managed care entity on a timely basis consistent with this chapter.
- (c) A clinical peer or other entity meets the independence requirements of this section if
- (1) the peer or entity does not have a familial, financial, or professional relationship with a related party;
- (2) compensation received by a peer or entity in connection with the external review is reasonable and not contingent on
any decision rendered by the peer or entity;
- (3) the plan and the issuer have no recourse against the peer or entity in connection with the external review; and
- (4) the peer or entity does not otherwise have a conflict of interest with a related party.
- (d) In this section, "related party" means
- (1) with respect to
- (A) a managed care plan, the plan or the insurer offering
the coverage; or
- (B) individual health insurance coverage, the insurer offering the coverage, or any plan sponsor, fiduciary, officer,
director, or management employee of the plan or issuer;
- (2) the health care professional that provided the health care involved in the coverage decision;
- (3) the institution at which the health care involved in the coverage decision is provided;
- (4) the manufacturer of any drug or other item that was included in the health care involved in the coverage decision;
- (5) the covered person; or
- (6) any other party that, under the regulations that the director may prescribe, is determined by the director to have a
substantial interest in the coverage decision.
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