58-17H-48 Notification of adverse determination--Requirements.
58-17H-48.
Notification of adverse determination--Requirements.
If a health carrier's
determination with respect to §§ 58-17H-40 to 58-17H-47, inclusive, is an adverse determination,
the health carrier shall provide notice of the adverse determination in accordance with this section.
A notification of an adverse determination under this section shall, in a manner calculated to be
understood by the covered person, set forth:
(1)
Information sufficient to identify the benefit request or claim involved, including the date
of service, if applicable, the health care provider, the claim amount, if applicable, the
diagnosis code and its corresponding meaning and the treatment code and its
corresponding meaning;
(2)
The specific reason or reasons for the adverse determination, including the denial code
and its corresponding meaning, as well as a description of the health carrier's standard, if
any, that was used in denying the benefit request or claim;
(3)
A reference to the specific plan provisions on which the determination is based;
(4)
A description of any additional material or information necessary for the covered person
to complete the request, including an explanation of why the material or information is
necessary to complete the request;
(5)
A description of the health carrier's internal review procedures established pursuant to
chapter 58-17I, including any time limits applicable to those procedures;
(6)
A description of the health carrier's expedited review procedures established pursuant to
§§ 58-17I-12 to 58-17I-16, inclusive;
(7)
If the health carrier relied upon an internal rule, guideline, protocol, or other similar
criterion to make the adverse determination, either the specific rule, guideline, protocol,
or other similar criterion or a statement that a specific rule, guideline, protocol, or other
similar criterion was relied upon to make the adverse determination and that a copy of the
rule, guideline, protocol, or other similar criterion will be provided free of charge to the
covered person upon request;
(8)
If the adverse determination is based on a medical necessity or experimental or
investigation treatment or similar exclusion or limit, either an explanation of the scientific
or clinical judgment for making the determination, applying the terms of the health benefit
plan to the covered person's medical circumstances, or a statement that an explanation
will be provided to the covered person free of charge upon request;
(9)
If applicable, instructions for requesting:
(a)
A copy of the rule, guideline, protocol, or other similar criterion relied upon in
making the adverse determination in accordance with subdivision (7) of this
section; or
(b)
The written statement of the scientific or clinical rationale for the adverse
determination in accordance with subdivision (8) of this section; and
(10)
A statement explaining the availability of and the right of the covered person, as
appropriate, to contact the Division of Insurance at any time for assistance or, upon
completion of the health carrier's grievance procedure process as provided under chapter
58-17I, to file a civil suit in a court of competent jurisdiction.
A health carrier may provide the notice required under this section orally, in writing or
electronically. If notice of the adverse determination is provided orally, the health carrier shall
provide written or electronic notice of the adverse determination within three days following the oral
notification. (SL 2012, ch 239, § 1 provides: "The provisions of chapter 219 of the 2011 Session
Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010,
Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final
decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals
elapsed.")
Source: SL 2011, ch 219, § 73.