This RSA section is an unofficial mirror, is not legal advice, and may be incomplete, outdated, or incorrectly processed.
RSA 420-J:5-a · Right to External Review
420-J:5-a Right to External Review. –
Copy linkA covered person shall have the right to independent external review of a determination by a health carrier or its designee utilization review entity when all of the following conditions apply:
Copy linkThe covered person has completed the internal review procedures provided by the carrier or other licensed entity pursuant to RSA 420-J:5, or the carrier or other entity has agreed to submit the determination to independent external review prior to completion of internal review, or the covered person has requested first or second level, standard or expedited review and has not received a decision from the carrier or other licensed entity within the required time frames; (c)(1) The covered person or the covered person's authorized representative has submitted the request for external review in writing to the commissioner within 180 days of the date of the carrier or other licensed entity's denial decision provided pursuant to RSA 420-J:5, or if the carrier or other licensed entity has failed to make a first or second level, standard or expedited review decision that is past due, within 180 days of the date the decision was due;
Copy linkThe covered person's or covered person's authorized representative's participation in any voluntary level of appeal offered by a carrier or other licensed entity pursuant to RSA 420-J:5, V(e)(2) shall not affect a covered person's ability to submit a request for external review. In the event that a covered person or covered person's authorized representative elects to proceed with a voluntary appeal, that person shall have 180 days from the date the decision is rendered on the voluntary appeal to submit a request for external review.
Copy linkThe health carrier determination does not relate to any category of health care services that is excluded from the external review provisions of this chapter pursuant to paragraph II; and
Copy linkThe request for external review is not based on a claim or allegation of provider malpractice, professional negligence, or other professional fault excluded from the external review provisions of this chapter pursuant to paragraph III.
Copy linkDeterminations relating to the following health care services shall not be reviewed under this chapter, but shall be reviewed pursuant to the review processes provided by applicable federal or state law:
Copy linkHealth care services provided through Medicaid, the state Children's Health Insurance Program (Title XXI of the Social Security Act ), Medicare or services provided under these programs but through a contracted health carrier, except where those services are provided through private insurance coverage pursuant to the New Hampshire granite advantage health care program under RSA 126-AA in which case all provisions of this chapter shall apply.
Copy linkHealth care services provided pursuant to a health plan not regulated by the state, such as self-funded plans administered by an administrative services organization or third-party administrator or federal employee benefit programs.
Copy linkThe external review procedures set forth in this chapter shall not be utilized to adjudicate claims or allegations of health care provider malpractice, professional negligence, or other professional fault against participating providers or medical directors. Source. 2000, 18:13. 2001, 207:15. 2005, 248:21. 2012, 98:1. 2015, 64:1, eff. Aug. 1, 2015. 2018, 342:17, eff. Dec. 31, 2018.
Copy linkSource note
Source. 2000, 18:13. 2001, 207:15. 2005, 248:21. 2012, 98:1. 2015, 64:1, eff. Aug. 1, 2015. 2018, 342:17, eff. Dec. 31, 2018.
Source history
- 2000, 18:13
- 2001, 207:15
- 2005, 248:21
- 2012, 98:1
- 2015, 64:1, eff. Aug. 1, 2015
- 2018, 342:17, eff. Dec. 31, 2018
Related materials
Bill relationships
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2026 HB1197
reference · effective 2027-01-01
description of the internal grievance procedure required under RSA 420-J:5 for claim denials and other matters and a description of the process for obtaining external review under RSA 420-J:5-a-RSA 420-J:5-e. These descriptions shall be set forth in or attached to the policy, certificate, membership booklet, or other evidence of coverage provided to covered persons. (2) A statement of a covered person's right t
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2026 HB1197-FN
reference · effective 2027-01-01
description of the internal grievance procedure required under RSA 420-J:5 for claim denials and other matters and a description of the process for obtaining external review under RSA 420-J:5-a-RSA 420-J:5-e. These descriptions shall be set forth in or attached to the policy, certificate, membership booklet, or other evidence of coverage provided to covered persons. (2) A statement of a covered person's right t
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2026 HB1268
reference · effective 2027-01-01
pharmacy or pharmacist to reverse and rebill the claim in question. (3) All claims adjudications, appeals, and utilization review processes shall comply with the requirements of RSA 420-J and rules promulgated thereunder. (b) For every drug for which the health carrier or pharmacy benefit manager establishes a maximum allowable cost to determine the drug product reimbursement, the health carrier or p
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2026 HB1323
amend · effective 2027-01-01
shall consider the factors set forth in RSA 461-A:6. 10 New Section; Managed Care Law; Prior Authorization for Physical Therapy and Occupational Therapy; When Required. Amend RSA 420-J by inserting after section 6-e the following new section: 420-J:6-f Prior Authorization for Physical Therapy and Occupational Therapy; When Required. I. A health carrier shall not require prior authorization for
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2026 HB1323-FN
amend · effective 2027-01-01
shall consider the factors set forth in RSA 461-A:6. 10 New Section; Managed Care Law; Prior Authorization for Physical Therapy and Occupational Therapy; When Required. Amend RSA 420-J by inserting after section 6-e the following new section: 420-J:6-f Prior Authorization for Physical Therapy and Occupational Therapy; When Required. I. A health carrier shall not require prior authorization for
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2026 HB1463
reference
nduct a detailed analysis and report, in consultation with practicing community physicians in every New Hampshire county and health system, to assess compliance with RSA 420-E and RSA 420-J and make recommendations for appropriate penalties for insurers and insurance carriers not in compliance with such chapters of law. The department shall report its findings to the speaker of the house of representative
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2026 HB1463-FN
reference
nduct a detailed analysis and report, in consultation with practicing community physicians in every New Hampshire county and health system, to assess compliance with RSA 420-E and RSA 420-J and make recommendations for appropriate penalties for insurers and insurance carriers not in compliance with such chapters of law. The department shall report its findings to the speaker of the house of representative
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2026 HB1638
amend
ep therapy protocols when medically necessary. Be it Enacted by the Senate and House of Representatives in General Court convened: 1 New Subdivision; Step Therapy. Amend RSA 420-J by inserting after section 26 the following new subdivision: Step Therapy 420-J:27 Definitions. As used in this subdivision: I. "Advanced, metastatic cancer" means a cancer that has spread from the primary or orig
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2026 HB1638-FN
amend
ep therapy protocols when medically necessary. Be it Enacted by the Senate and House of Representatives in General Court convened: 1 New Subdivision; Step Therapy. Amend RSA 420-J by inserting after section 26 the following new subdivision: Step Therapy 420-J:27 Definitions. As used in this subdivision: I. "Advanced, metastatic cancer" means a cancer that has spread from the primary or orig
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2026 HB1744
amend
Be it Enacted by the Senate and House of Representatives in General Court convened: 1 New Section; Managed Care Law; Mental Health Coverage Reporting and Oversight. Amend RSA 420-J by inserting after section 6-e the following new section: 420-J:6-e Mental Health Coverage Reporting and Oversight. I. Each health insurance carrier offering health benefit plans in this state shall submit an annual r
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2026 HB1744-FN
amend
Be it Enacted by the Senate and House of Representatives in General Court convened: 1 New Section; Managed Care Law; Mental Health Coverage Reporting and Oversight. Amend RSA 420-J by inserting after section 6-e the following new section: 420-J:6-e Mental Health Coverage Reporting and Oversight. I. Each health insurance carrier offering health benefit plans in this state shall submit an annual r
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2026 HB241
amend · effective 2027-01-01
sed standards used in deciding which therapies should be available. 2 New Section; Managed Care Law; Development of a Comprehensive Program of Pain Management Services for the Management of Chronic Pain. Amend RSA 420-J by inserting after section 7-e the following new section: 420-J:7-f Development of a Comprehensive Program of Pain Management Services for the Management of Chronic Pain. I. Health carriers shall develop, in a