2. shall be permitted to utilize the assistance of other individuals, including health care providers, attorneys, friends, and family members throughout the review process; 3. shall be permitted to submit additional information relating to the proposed service throughout the review process; and 4. shall cooperate with the independent review organization by: a. providing any requested medical information; or b. authorizing the release of necessary medical information. We shall cooperate with an independent review organization by promptly providing any information requested by the independent review organization. An independent review organization shall: 1. for an expedited external grievance, within 3 business days after the external grievance is filed; or 2. for a standard appeal, within 15 business days after the appeal is filed; make a determination to uphold or reverse Our appeal resolution of a grievance based on information gathered from the Covered Person or the Covered Person's designee, Us, and the treating health care provider, and any additional information
that the independent review organization considers necessary and appropriate. When making the determination, the independent review organization shall apply: 1. standards of decision making that are based on objective clinical evidence; and 2. the terms of the Covered Person's accident and sickness insurance policy.
In an external grievance, We bear the burden of proving that We properly denied coverage for a condition, complication, service, or treatment because the condition, complication, service, or treatment is directly related to a condition for which coverage has been waived under IC 27-8-5-2.5 or IC 27-8-5-19.2.
The independent review organization shall notify Us and the Covered Person of their determination: 1. for an expedited external grievance, within 24 hours after making the determination; and 2. for a standard external grievance, within 72 hours after making the determination.
Upon the request of a Covered Person who is notified that the independent review organization has made a determination, the independent review organization shall provide to the Covered Person all information reasonably necessary to enable the Covered Person to understand the: 1. effect of the determination on the Covered Person; and 2. manner in which We may be expected to respond to the determination. A determination made under this external review of grievances procedure is binding on Us. If, at any time during an external review performed, the Covered Person submits information to Us that is relevant to Our resolution of the Covered Person's appeal of a grievance decision and that was not considered by Us: 1. We may reconsider the resolution; and 2. if We choose to reconsider, the independent review organization shall cease the external review process until the reconsideration is completed. If We reconsider the resolution of an appeal of a grievance decision due to the submission of new information, We shall reconsider the resolution based on the information, and notify the Covered Person of Our decision: 1. within 72 hours after the information is submitted, for a reconsideration related to an illness, a disease, a condition, an injury, or a disability that would seriously jeopardize the Covered Person's life or health, or ability to reach and maintain maximum function; or 2. within 15 days after the information is submitted, for a reconsideration not described in item 1. above. If the decision reached is adverse to the Covered Person, the Covered Person may request that the independent review organization resume the external review. If We choose not to reconsider Our resolution of a grievance, We shall forward the submitted information to the independent review organization not more than 2 business days after Our receipt of the information. Louisiana residents:
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