§432E-6 Appeals to the commissioner. (a) After exhausting all internal complaint and appeal procedures available, an enrollee, or the enrollee's treating provider or appointed representative, may appeal an adverse decision of a managed care plan to a three-member review panel appointed by the commissioner composed of a representative from a health plan not involved in the complaint, a provider licensed to practice and practicing medicine in Hawaii not involved in the complaint, and the commissioner or the commissioner's designee in the following manner:
(1) The enrollee shall submit a request for review to the commissioner within thirty days from the date of the final determination by the managed care plan;
(2) Upon receipt of the request and upon a showing of good cause, the commissioner shall appoint the members of the panel and shall conduct a review hearing pursuant to chapter 91. If the amount in controversy is less than $500, the commissioner may conduct a review hearing without appointing a review panel;
(3) The review hearing shall be conducted as soon as practicable, taking into consideration the medical exigencies of the case; provided that the hearing shall be held no later than sixty days from the date of the request for the hearing;
(4) The commissioner may retain, without regard to chapters 76 and 77, an independent medical expert trained in the field of medicine most appropriately related to the matter under review. Presentation of evidence for this purpose shall be exempt from section 91-9(g);
(5) After considering the enrollee's complaint, the plan's response, and any affidavits filed by the parties, the commissioner may dismiss the appeal if it is determined that the appeal is frivolous or without merit; and
(6) The review panel shall review every adverse determination to determine whether or not the plan involved acted reasonably and with sound medical judgment. The review panel shall consider the clinical standards of the plan, the information provided, the attending physician's recommendations, and generally accepted practice guidelines.
The commissioner, upon a majority vote of the panel, shall issue an order affirming, modifying, or reversing the decision within thirty days of the hearing.
(b) The procedure set forth in this section shall not apply to claims or allegations of health provider malpractice, professional negligence, or other professional fault against participating providers.
(c) Members of the review panel shall be granted immunity from liability and damages relating to their duties under this section.
(d) An enrollee may be allowed, at the commissioner's discretion, an award of a reasonable sum for attorney's fees and reasonable costs of suit in an action brought against the managed care plan. [L 1998, c 178, pt of §2; am L 1999, c 137, §6]