subparagraph (i), additional information that the IRO
shall consider when conducting the external review. The
IRO may accept and consider additional information
submitted after five business days.
(2) Within one business day of the receipt of the notice
of assignment to conduct the external review under paragraph
(1), the assigned IRO shall:
(i) Select one or more clinical reviewers under
paragraph (3) to conduct the external review.
(ii) Based on the opinion or opinions of the
clinical reviewer or reviewers, make a decision to uphold
or reverse the adverse benefit determination or final
adverse benefit determination.
(3) In selecting a clinical reviewer, the assigned IRO
shall select a physician or other health care provider who
meets the minimum qualifications described in section 2611.1
and, through clinical experience in the past three years, has
expertise in the treatment of the covered person's condition
and is knowledgeable about the recommended or requested
health care service. The covered person, the covered person's
authorized representative and, if applicable, the insurer may
not choose or control the choice of the physician or other
health care provider to be selected to conduct the external
review.
(4) In accordance with subsection (e), each clinical
reviewer shall provide a written opinion to the assigned IRO
regarding whether the recommended or requested health care
service should be covered.
(5) The assigned clinical reviewer is not bound by a
decision or conclusion reached during the insurer's internal
claims and appeal process under section 2164.
(e) Forwarding of required documents.--
(1) Within five business days of the date of receipt of
the notice provided under subsection (d)(1), the insurer, or
a utilization review organization designated by the insurer,
shall provide to the assigned IRO the documents and
information considered in making the adverse benefit
determination or the final adverse benefit determination.
(2) Except as provided in paragraph (3), failure by the
insurer, or by a utilization review organization designated
by the insurer, to provide the documents and information
within the time period specified in paragraph (1) may not
delay the conduct of the external review.
(3) If the insurer, or a utilization review organization
designated by the insurer, fails to provide the documents and
information within the time period specified in paragraph
(1), the assigned IRO may terminate the external review and
make a decision to reverse the adverse benefit determination
or final adverse benefit determination. Within 24 hours upon
making the decision, the IRO shall notify the department, the
insurer, the covered person, and, if applicable, the covered
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