E.__An independent external review must be conducted by an independent review organization pursuant to a contract with the bureau.__The reviewers must be health care providers credentialed with respect to the health care service under review and have no conflict of interest relating to the performance of their duties under this subsection.

F.__The independent review organization shall issue a written decision based on the evidence presented to the health plan and the enrollee.__The decision of the review organization is binding on the health plan and the enrollee.

G.__The superintendent may develop additional standards and adopt rules to set the fee required in paragraph C and to adopt other rules as necessary to carry out the purposes of this subsection in accordance with section 4309.

SUMMARY

This bill amends the Health Plan Improvement Act to prohibit carriers offering managed care plans from paying financial incentives to participating providers to deny, reduce or limit medically necessary health care services to enrollees. The bill also gives health plan enrollees the right to an independent external review of a plan's coverage decision after all internal grievance and appeals procedures have been exhausted.