58-17I-15 Expedited review decision--Notification--Required contents.
58-17I-15.
Expedited review decision--Notification--Required contents.
A notification of a
decision under §§ 58-17I-12 to 58-17I-15, inclusive, shall, in a manner calculated to be understood
by the covered person or, if applicable, the covered person's authorized representative, set forth the
following:
(1)
The titles and qualifying credentials of any person participating in the expedited review
process (the reviewer);
(2)
Information sufficient to identify the claim involved with respect to the grievance,
including the date of service, the health care provider, if applicable, the claim amount, the
diagnosis code and its corresponding meaning, and the treatment code and its
corresponding meaning;
(3)
A statement of the reviewer's understanding of the covered person's grievance;
(4)
The reviewer's decision in clear terms and the contract basis or medical rationale in
sufficient detail for the covered person to respond further to the health carrier's position;
(5)
A reference to the evidence or documentation used as the basis for the decision;
(6)
If the decision involves a final adverse determination, the notice shall provide:
(a)
The specific reason or reasons for the final 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 reaching the denial;
(b)
A reference to the specific plan provisions on which the determination is based;
(c)
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;
(d)
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;
(e)
If the final adverse determination is based on a medical necessity or experimental
or investigational 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;
(f)
If applicable, instructions for requesting:
(i)
A copy of the rule, guideline, protocol, or other similar criterion relied upon
in making the adverse determination as provided in subsection (d) of this
section; or
(ii)
The written statement of the scientific or clinical rationale for the adverse
determination as provided in subsection (e) of this section;
(g)
A statement describing the procedures for obtaining an independent external
review of the adverse determination pursuant to rules promulgated by the director;
(h)
A statement indicating the covered person's right to bring a civil action in a court
of competent jurisdiction;
(i)
The following statement: "You and your plan may have other voluntary alternative
dispute resolution options, such as mediation. One way to find out what may be
available is to contact your state insurance director."; and
(j)
A notice of the covered person's right to contact the Division of Insurance for
assistance at any time, including the telephone number and address of the Division
of Insurance.
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 date
of 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, § 87.