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RSA 420-J:5-e · General Provisions Regarding External Review
420-J:5-e General Provisions Regarding External Review. –
Copy linkThe health carrier against which a request for external review is filed shall pay the cost of the external review. Except under the circumstances described below in this paragraph, such costs shall not exceed $1,500. The commissioner shall notify the independent review organizations of the cost limitation for conducting an external review. The cost for an external review may exceed $1,500 if the commissioner determines an additional cost is necessary to ensure the fair adjudication of the case in question.
Copy linkThe external review decision of the independent review organization shall be binding on the health carrier and shall be enforceable by the commissioner pursuant to the penalty provisions of RSA 420-J:14. The external review decision of the independent review organization shall be binding on the covered person except to the extent the covered person has other remedies available under federal or state law. The external review process shall not be considered an adjudicative proceeding within the meaning of RSA 541-A, and the external review decision of the independent review organization shall not be subject to rehearing and appeal pursuant to RSA 541.
Copy linkAn independent review organization shall maintain all standards of confidentiality. The records and internal materials prepared for specific reviews by an independent review organization under this section shall be exempt from public disclosure under RSA 91-A.
Copy linkAn external review organization acting in good faith shall have immunity from any civil or criminal liability or professional discipline as a result of acts or omissions with respect to any external review, unless the acts or omissions constitute willful and wanton misconduct.
Copy linkThe right to external review under this chapter shall not be construed to change the terms of coverage under a health benefit plan nor shall the health carrier retaliate against the covered person for exercising his or her right to an independent external review.
Copy linkWhen requested by the covered person, the commissioner shall provide consumer assistance in pursuing the internal grievance procedures under RSA 420-J:5 and the external review process under RSA 420-J:5-a-420-J:5-e.
Copy linkThe commissioner shall report annually to the governor and the legislature on the number of grievances subjected to external review, the number of decisions resolved wholly or partially in favor of the covered person, and the number of decisions resolved wholly or partially in favor of the health carrier. Such reports shall also include a separate statement of the number of cases in which the external review was terminated as a result of a reversal by the health carrier of its adverse determination after the receipt of new or additional information from the covered person or the covered person's authorized representative and the number of cases in which the covered person and the health carrier agreed to resolve the dispute prior to a final determination by the independent review organization.
Copy linkIf, based on the evidence presented during the external review process, the commissioner determines that the health carrier's medical director, in the conduct of his or her duties, may have committed misconduct as set forth in RSA 329:17, VI, the commissioner shall document such findings and transmit them in a separate report to the board of medicine. Source. 2000, 18:13, eff. Sept. 3, 2000.
Copy linkSource note
Source. 2000, 18:13, eff. Sept. 3, 2000.
Source history
- 2000, 18:13, eff. Sept. 3, 2000
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Bill relationships
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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
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2026 HB241-FN
amend · effective 2027-01-01
ich 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 accorda
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2026 HB705
amend · effective 2026-03-16
transparency. Be it Enacted by the Senate and House of Representatives in General Court convened: 5:1 New Subdivision; Managed Care Law; Transparency in Coverage. Amend RSA 420-J by inserting after section 26 the following new subdivision: Transparency in Coverage 420-J:27 Definitions. In this subdivision: I. “Billed charge” means the total charges for an item or service billed to a healt