HB 2599 Summary

• Replaces terminology "adverse decision" with "adverse determination" throughout health care appeals processes and adds new definitions including "final internal adverse determination," "grandfathered individual plan," "health care setting," "internal levels of review," and "rescission."

• Establishes three mandatory internal appeal levels for group and grandfathered individual plans: expedited medical review, initial appeal, and optional voluntary internal appeal, with specific timeframes (15-30 days for services not yet provided, 30-60 days for claims already provided).

• Requires health care insurers to provide written determinations including basis, criteria used, clinical reasons and rationale for adverse determinations, and allows members to proceed to external independent review if internal levels are exhausted or not complied with.

• Expands external independent review standards to require consideration of evidence-based practice guidelines, clinical review criteria, treating provider recommendations, and for experimental or investigational services, FDA approval status and medical evidence demonstrating expected benefits outweigh risks.

• Requires health care insurers and independent review organizations to maintain all records related to internal and external appeals for at least three years after completion of the appeals process.