STANDARDS FOR ACCIDENT AND HEALTH INSURANCE
415-A:4-b Appeal Procedure.
Every carrier or other licensed entity which offers group health insurance or employee benefit plans shall file with the insurance department, by April 1 of each year, and shall maintain a written procedure by which a claimant, or a representative of the claimant, shall have a reasonable opportunity to appeal a claim denial to the carrier or other licensed entity, and under which there shall be a full and fair review of the claim denial. The written procedure filed with the insurance department shall include all forms used to process an appeal.
I. Full and fair review shall require that:
(a) The person or persons reviewing the grievance shall not be the same person or persons making the initial determination, shall not be subordinate to or the supervisor of the person making the initial determination, and shall act as a fiduciary;
(b) The person reviewing the grievance on a first or second level appeal shall have appropriate medical and professional expertise and credentials to competently render a determination on appeal;
(c) The claimant or claimant's representative shall have at least 180 days following receipt of a notification of an adverse claim determination to appeal;
(d) The claimant or claimant's representative shall have an opportunity to submit written comments, documents, records, and other information relating to the claim without regard to whether those documents or materials were considered in making the initial determination;
(e) The claimant or claimant's representative shall be provided upon request, and without charge, reasonable access to, and copies of all documents, records, and other information relevant to or considered in making the initial adverse claim determination; and
(f) The review shall be a de novo proceeding and shall consider all information, documents, or other material submitted in connection with the appeal without regard to whether the information was considered in making the claim denial.
II. In the appeal of a claim denial that is based in whole or in part on a medical judgment:
(a) The review shall be conducted by or in consultation with a health care professional who has appropriate training and experience in the field of medicine;
(b) The titles and qualifying credentials of the person conducting the review shall be included in the decision; and
(c) The identity and qualifications of any medical or vocational expert whose advice was considered, without regard to whether it was relied upon in making the initial claim denial, shall be made available to the claimant upon request.
III. In the appeal of a claim for urgent care, a claim involving a matter that would seriously jeopardize the life or health of a covered person or would jeopardize the covered person's ability to regain maximum function, or a claim concerning an admission, availability of care, or the continued stay or health care service for a person who has received emergency services, but who has not been discharged from a facility, an expedited appeal process shall be made available which shall provide for:
(a) The submission of information by the claimant to the carrier by telephone, facsimile, or other expeditious method; and
(b) The determination of the appeal shall be made not more than 72 hours after the submission of the completed request for appeal.
IV. Timing and Notification for Determination on Appeal.
(a) In the case of nonexpedited appeal of a pre-service claim or a post-service claim, the determination on appeal shall be made within a reasonable time appropriate to the medical circumstances, but in no event more than 30 days after receipt by the carrier or other licensed entity of the claimant's appeal.
(b) In the case of an expedited appeal related to an urgent care claim, a carrier or other licensed entity shall make a decision and notify the covered person as expeditiously as the covered person's medical condition requires, but in no event more than 72 hours after the appeal is filed. If the expedited review involves ongoing urgent care services, the service shall be continued without liability to the covered person until the covered person has been notified of the determination. A carrier or other licensed entity shall provide written confirmation of its decision concerning an expedited review within 2 business days of providing notification of that decision, if the initial notification was not in writing.
(c) The period of time within which a decision shall be rendered on appeal shall begin to run at the time the appeal is filed in accordance with the appeal procedures of the carrier or other licensed entity, without regard to whether all the information necessary to make a determination on appeal is contained in the filing. In the event the claimant fails to submit information necessary to decide the appeal, the period for making the determination on appeal shall be tolled from the date the claimant is notified in writing of what additional information is required until the date the claimant responds to the request. The carrier or other licensed entity shall provide notification of incompleteness as soon as possible; but in no event more than 24 hours after the filing of the appeal in appeals involving urgent care. In the event that the claimant fails, within a 45-day period from the date of notification, to provide sufficient information, the carrier may deny the appeal on the basis of incompleteness. The appeal may be reopened upon receipt of the required information.
V. Manner and Content of Notification of Determination on Appeal.
(a) The carrier or other licensed entity shall provide a claimant with a written determination of the appeal that shall include:
(1) The specific reason or reasons for the determination, including reference to the specific provision of the policy or plan on which the determination is based;
(2) If the determination is based upon a finding that the claim is experimental or investigational or not medically necessary or appropriate:
(A) The name and credentials of the person reviewing the grievance, including board status and the state or states where the person is currently licensed; and
(B) An explanation of the clinical rationale for the determination. This explanation shall recite the terms of the plan or the policy or of any clinical review criteria or any internal rule, guideline, protocol, or other similar provision that was relied upon in making the claim denial and how these provisions apply to the claimant's specific medical circumstance;
(3) A statement describing all other dispute resolution options available to the claimant, including, but not limited to other options for internal review and options for external review, and options for bringing a legal action;
(4) A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits;
(5) If an internal rule, guideline, protocol, or other similar provision was relied upon in making the claim denial, a statement that such rule, guideline, protocol, or other similar provision was relied upon in making the claim denial; and
(6) A statement describing the claimant's right to contact the insurance commissioner's office for assistance which shall include a toll-free telephone number and address of the commissioner.
(b) A carrier or other licensed entity that offers group health plans or employee benefit plans shall file with the commissioner by April 1 of each year, a copy of its current grievance procedures, with all changes from the previous year annotated in the document, and a certificate of compliance , stating that the carrier or other licensed entity has established and maintained, for each of its health benefit plans, grievance procedures that fully comply with the provisions of this chapter. Material modifications to the procedure shall be filed with the commissioner prior to becoming effective.
(c) A carrier or other licensed entity that offers group health plans or employee benefit plans shall maintain written records documenting all grievances and appeals received during a calendar year, a general description of the reason for the appeal or grievance, the name of the claimant, the dates of the appeal or grievance and the date of resolution.
(d) A carrier or other licensed entity that offers group health plans or employee benefit plans shall provide to consumers:
(1) A description of the internal grievance procedure for claim determinations and other matters. The description shall be set forth in or attached to the policy, certificate, membership booklet, or other evidence of coverage provided to covered persons;
(2) A statement of a covered person's right to contact the commissioner's office for assistance at any time. The statement shall include the toll-free telephone number and address of the commissioner; and
(3) A statement that the carrier or other licensed entity will provide assistance in preparing an appeal of an adverse benefit determination, and a toll-free telephone number to contact the carrier or other licensed entity.
(e) In any case where a carrier or other licensed entity that offers group health plans or employee benefit plans provides 2 levels of appeal for the pre-service claim determinations, the first level shall be completed within 15 days and the second level completed within the 30-day time period beginning from the initial date of filing the appeal or grievance. With respect to a second level appeal involving a claim for continuation of services or urgent care, the carrier or other licensed entity shall make a decision and notify the claimant within 72 hours after the second level appeal is filed. For second level appeals involving a post-service claim, the carrier shall make a decision and notify the claimant within 60 days of the date the appeal was filed.
(f) Annual reports shall be made to the insurance commissioner regarding plan complaints, claim denials, and prior authorization statistics in such form and containing such information as the commissioner may prescribe by rule or otherwise.
VI. In an appeal of a claim denial or other matter, the claimant may authorize a representative to pursue a claim or an appeal by submitting a written statement to the carrier or other licensed entity that acknowledges the representation.
VII. No fees or costs shall be assessed against a claimant related to a request for a grievance or appeal.
Source. 2001, 207:3. 2003, 175:5, 6. 2006, 304:3. 2007, 289:9. 2012, 99:2, eff. July 28, 2012.