HB5473 Summary

• Requires accident or health insurance policies and managed care plans to establish and maintain appeals procedures for denials of health care benefits.

• Establishes expedited appeal process (24-hour decision) for ongoing treatments or procedures where denial could significantly increase health risk to enrollee.

• Provides right to external independent review by clinical peer if initial appeal is denied based on medical necessity determination, with decision required within 5 days (or 24 hours in urgent cases).

• Requires policies and plans to pay all fees for external independent reviewers and provide written notification to enrollees about appeal and external review processes.

• Applies requirements to state employees group insurance, counties, municipalities, school districts, and various insurance entities including HMOs, limited health service organizations, and voluntary health service plans.