33-46-22. Review of appeals by appropriate healthcare provider.

A private review agent or utilization review entity shall ensure that all appeals are reviewed by an appropriate healthcare provider who shall:

Possess a current and valid nonrestricted license or maintain other appropriate legal authorization;#

Be currently in active practice in the same or similar specialty and who typically manages the medical condition or disease;#

Be knowledgeable of, and have experience providing, the healthcare service under appeal;#

Not have been directly involved in making the adverse determination; and#

Consider all known clinical aspects of the healthcare service under review, including, but not limited to, a review of all pertinent medical or other records provided to the private review agent or utilization review entity by the covered person’s healthcare provider, any relevant records provided to such agent or entity by a facility, and any medical or other literature provided to such agent or entity by the healthcare provider.#