<?xml version='1.0' encoding='utf-8'?>
<section article="gin" article_name="Insurance" number="15-10B-09.1" title_number="15" title_name="Health Insurance" subtitle_number="10B" subtitle_name="Private Review Agents">
  <text>A grievance decision shall be made based on the professional judgment of:</text>
  <level label="1">
    <level label="i">
      <text>a licensed physician who is board certified or eligible in the same specialty as the treatment under review and knowledgeable about the requested health care service or treatment through actual clinical experience; or</text>
    </level>
    <level label="ii">
      <text>a panel of other appropriate health care service reviewers with at least one licensed physician on the panel who is board certified or eligible in the same specialty as the treatment under review and knowledgeable about the requested health care service or treatment through actual clinical experience;</text>
    </level>
  </level>
  <level label="2">
    <text>when the grievance decision involves a dental service, a licensed dentist, or a panel of appropriate health care service reviewers with at least one dentist on the panel who is a licensed dentist, who shall consult with a dentist who is board certified or eligible in the same specialty as the service under review and knowledgeable about the requested health care service or treatment through actual clinical experience; or</text>
  </level>
  <level label="3">
    <text>when the grievance decision involves a mental health or substance abuse service:</text>
    <level label="i">
      <text>a licensed physician who:</text>
      <level label="1">
        <text>is board certified or eligible in the same specialty as the treatment under review; or</text>
      </level>
      <level label="2">
        <text>is actively practicing or has demonstrated expertise in the substance abuse or mental health service or treatment under review; or</text>
      </level>
    </level>
    <level label="ii">
      <text>a panel of other appropriate health care service reviewers with at least one licensed physician, selected by the private review agent who:</text>
      <level label="1">
        <text>is board certified or eligible in the same specialty as the treatment under review; or</text>
      </level>
      <level label="2">
        <text>is actively practicing or has demonstrated expertise in the substance abuse or mental health service or treatment under review.</text>
      </level>
    </level>
  </level>
</section>
