R590. Insurance, Administration.
R590-203. Health Grievance Review Process and Disability Claims.
(Effective 12-28-05)
R590-203-1. Authority.
This rule is specifically authorized by 31A-22-629(4) and 31A-4-116, which
requires the commissioner to establish minimum standards for grievance review
procedures. The rule is also promulgated pursuant to Subsections 31A-2-201(1)
and 31A-2-201(3)(a) in which the commissioner is empowered to administer and
enforce this title and to make rules to implement the provisions of this title.
The authority to examine insurer records, files, and documentation is provided
by 31A-2-203.
R590-203-2. Purpose.
The purpose of this rule is to ensure that insurer's grievance review
procedures for individual and group health insurance and income replacement
plans comply with the Department of Labor, Pension and Welfare Benefits
Administration Rules and Regulations for Administration and Enforcement: Claims
Procedure, 29 CFR 2560.503-1, Utah Code Sections 31A-4-116 and 31A-22-629.
R590-203-3. Applicability and Scope.
(1) Except as provided in R590-203-3.(3), this rule
applies to individual and group:
(a) policies issued or renewed and effective on or after January 1,
2001;
(b) income replacement policies;
(i) including short-term, and
(ii) long-term disability policies;
(c) health insurance; and
(d) health maintenance organization contracts.
(2) Long Term Care and Medicare supplement policies are not considered
health insurance for the purpose of this rule.
(3) Income replacement, short-term and long-term disability policies,
are exempt from R590-203-6.
R590-203-4. Definitions.
For the purposes of this rule:
(1) “Consumer Representative” may be an employee of the insurer who is a
consumer of a health insurance or an income replacement policy, as long as the
employee is not[;]:
(a) the individual who made the adverse determination[,];
or
(b) a subordinate to the individual who made the adverse determination.
(2) “Health Insurance” means a contract of:
(a) health care insurance as defined in 31A-1-301; and
(b) health maintenance organization as defined in 31A-8-101.
(3) "Medical Necessity" means:
(a) health care services or products that a prudent health care
professional would provide to a patient for the purpose of preventing,
diagnosing or treating an illness, injury, disease or its symptoms in a manner
that is:
(i) in accordance with generally accepted standards of medical practice in
the United States;
(ii) clinically appropriate in terms of type, frequency, extent, site, and
duration;
(iii) not primarily for the convenience of the patient, physician, or other
health care provider; and
(iv) covered under the contract; and
(b) that when a medical question-of-fact exists medical necessity shall
include the most appropriate available supply or level of service for the
individual in question, considering potential benefits and harms to the
individual, and known to be effective.
(i) For interventions not yet in widespread use, the effectiveness shall be
based on scientific evidence.
(ii) For established interventions, the effectiveness shall be based on:
(A) scientific evidence;
(B) professional standards; and
(C) expert opinion.
(4)(a) "Scientific evidence" means:
(i) scientific studies published in or accepted for publication by medical
journals that meet nationally recognized requirements for scientific manuscripts
and that submit most of their published articles for review by experts who are
not part of the editorial staff; or
(ii) findings, studies or research conducted by or under the auspices of
federal government agencies and nationally recognized federal research
institutes.
(b) Scientific evidence shall not include published peer-reviewed literature
sponsored to a significant extent by a pharmaceutical manufacturing company or
medical device manufacturer or a single study without other supportable
studies.
R590-203-5. Adverse Benefit Determination.
(1) An insurer's adverse benefit determination review procedure shall be
compliant with the adverse benefit determination review requirements set forth
in the Department of Labor, Pension and Welfare Benefits Administration Rules
and Regulations for Administration and Enforcement: Claims Procedure, 29 CFR
2560.503-1, effective January 20, 2001. This document is incorporated by
reference and available for inspection at the Insurance Department and the
Department of Administrative Rules.
(2) The provision of this rule and federal regulation applies to claims
filed under individual or group plans on or after the first day of the first
plan year beginning on or after July 1, 2002, but no later than January 1, 2003.
(3) An insurer's adverse benefit determination appeal board or body shall
include at least one consumer representative that shall be present at every
meeting.
R590-203-6. Independent and Expedited Adverse Benefit Determination
Reviews for Health Insurance.
(1) An insurer shall provide an independent review procedure as a voluntary
option for the resolution of adverse benefit determinations of medical
necessity.
(2) An independent review procedure shall be conducted by an independent
review organization, person, or entity other than the insurer, the plan, the
plan's fiduciary, the employer, or any employee or agent of any of the
foregoing, that do not have any material professional, familial, or financial
conflict of interest with the health plan, any officer, director, or management
employee of the health plan, the enrollee, the enrollee's health care provider,
the provider's medical group or independent practice association, the health
care facility where service would be provided and the developer or manufacturer
of the service being provided.
(3) Independent review organizations shall be designated by the insurer, and
the independent review organization chosen shall not own or control, be a
subsidiary of, or in any way be owned or controlled by, or exercise control with
a health insurance plan, a national, state, or local trade association of health
insurance plans, and a national, state, or local trade association of health
care providers.
(4) The submission to an independent review procedure is purely voluntary
and left to the discretion of the claimant.
(5) An insurer's voluntary independent review procedure shall:
(a) waive any right to assert that a claimant has failed to exhaust
administrative remedies because the claimant did not elect to submit a dispute
of medical necessity to a voluntary level of appeal provided by the plan;
(b) agree that any statute of limitations or other defense based on
timeliness is tolled during the
time a voluntary appeal is pending;
(c) allow a claimant to submit a dispute of medical necessity to a voluntary
level of appeal only after exhaustion of the appeals permitted under 29 CFR
Subsection 2560.503-1(c)(2), of the Department of Labor, Pension and Welfare
Benefits Administration Rules and Regulation for the Administration and
Enforcement: Claims Procedure;
(d) upon request from any claimant, provide sufficient information
relating to the voluntary level of appeal to enable the claimant to make an
informed decision about whether to submit a dispute of medical necessity to the
voluntary level of appeal. This information shall contain a statement that the
decision to use a voluntary level of appeal will not effect the claimant's
rights to any other benefits under the plan and information about the applicable
rules, the claimants right to representation, the process for selecting the
decision maker.
(e) An independent review conducted in compliance with Section
31A-22-629, and this rule, can be binding on both parties. A claimant’s
submission to a binding independent review is purely voluntary and appropriate
disclosure and notification must be given as required by the Department of
Labor, Pension and Welfare Benefits Administration Rules and Regulations for
Administration and Enforcement: Claims Procedure, 29 CFR 2560.503‑1.
(6) Standards for voluntary independent review:
(a) The insurer's internal adverse benefit determination process must be
exhausted unless the insurer and insured mutually agree to waive the internal
process.
(b) Any adverse benefit determination of medical necessity may be the
subject of an independent review.
(c) The claimant has 180 calendar days from the date of the final internal
review decision to request an independent review.
(d) An insurer shall use the same minimum standards and times of
notification requirement for an independent review that are used for internal
levels of review, as set forth in 29 CFR Subsection 2560.503-1(h)(3), (i)(2) and
(j).
(7) An insurer shall provide an expedited review process for cases involving
urgent care claims.
(8) A request for an expedited review of an adverse benefit determination of
medical necessity may be submitted either orally or in writing. If the request
is made orally an insurer shall, within 24 hours, send written confirmation to
the claimant acknowledging the receipt of the request for an expedited review.
(9) An expedited review requires:
(a) all necessary information, including the plan's original benefit
determination, be transmitted between the plan and the claimant by telephone,
facsimile, or other available similarly expeditious method;
(b) an insurer to notify the claimant of the benefit review determination,
as soon as possible, taking into account the medical urgency, but not later than
72 hours after receipt of the claimant's request for review of an adverse
benefit determination; and
(c) an insurer to use the same minimum standard for timing and notification
as set forth in 29 CFR Subsection 2560.503-1(h), 503-1(i)(2)(i), and 503-1(j).
(10) This section, R590-203-6, does not apply to income replacement
policies, short term disability policies or long term disability policies.
R590-203-7. Income Replacement, Short-Term and
Long-Term Disability, Adverse Benefit Determination Review.
(1) An insurer will notify a claimant of the benefit determination
within 45 days of receipt of the claimant's
request for review of an adverse benefit determination.
(2) The time period for
making a determination on review may be extended for up to 45 days when
necessary due to matters beyond the control of the insurer.
(3) If
the time period is extended due to the claimant's failure to submit information
necessary to decide a claim, the time period for making the benefit
determination on review shall be tolled from the date on which the notification
of the extension is sent until the date on which the claimant responds to the
request for additional information.
(4) Upon request, relevant information free-of-charge, must be provided to
the insured on any adverse benefit determination.
R590-203-8. File and Record Documentation.
An insurer selling health insurance or income replacement insurance,
including short-term disability and long-term disability, shall make available
upon request by the commissioner, or the commissioner's duly appointed
designees, all adverse benefit determination reviews files and related
documentation. An insurer shall keep these records for the current calendar
year plus five years.
R590-203-9. Compliance.
(1) Insurers are to be compliant with the provisions of this rule and the
Department of Labor, Pension and Welfare Benefits Administration Rules and
Regulations for Administration and Enforcement: Claims Procedure, 29 CFR
2560.503-1, by July 1, 2002.
(2) The clarification changes made for income replacement and short-term
and long-term disability policies are effective on the date these rule changes
take effect.
R590-203-10. Relationship to Federal Rules.
If an insurer complies with the requirements of the Department of Labor,
Pension and Welfare Benefits Administration Rules and Regulations for
Administration and Enforcement: Claims Procedure, 29 CFR 2560.503-1, then this
rule is not applicable to employer plans, except for Sections 4, 5, 6, 7, and 8
of this rule. All individual plans will remain subject to this rule in its
entirety.
R590-203-11. Severability.
If a provision or clause of this rule or its application to any person or
circumstance is for any reason held to be invalid, the remainder of the rule and
the application of these provisions shall not be affected.
KEY: insurance
2005
31A-2-201
31A-2-203
31A-4-116
31A-22-629
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