Adverse Benefit Determination
See the bold text below:
R590. Insurance, Administration.
R590-203. Health Grievance Review Process.
R590-203-1. Authority.
This rule is promulgated by the commissioner pursuant to Sections 31A-2-201, 31A-2-203, and 31A-22-629.
R590-203-2. Purpose and Scope.
(1) The purpose of this rule is to ensure that a carrier’s grievance review procedure for an individual and a group health insurance and disability income insurance plan complies with 29 CFR 2560.503-1, and Sections 31A-4-116 and 31A-22-629.
(2) This rule applies to individual and group:
(a) health insurance;
(b) disability income insurance; and
(c) health maintenance organization contracts.
(3) Long term care and Medicare supplement policies are not considered health insurance under this rule.
(4) A disability income insurance policy is exempt from R590-203-5.
(5) This rule does not apply to a health benefit plan that complies with R590-261, Health Benefit Plan Adverse Benefit Determinations.
R590-203-3. Definitions.
Terms used in this rule are defined in Sections 31A-1-301 and 31A-22-629. Additional terms are defined as follows:
(1) “Carrier” means a person or entity providing health insurance or disability income insurance including:
(a) an insurance company;
(b) a prepaid hospital or medical care plan;
(c) a health maintenance organization;
(d) a multiple employer welfare arrangement;
(e) a managed care organization; and
(f) any other person or entity providing a health insurance or disability income insurance plan under Title 31A, Insurance Code.
(2) “Consumer representative” means an employee of a carrier who represents a consumer perspective, if the employee is not:
(a) the individual who made the adverse benefit determination; or
(b) subordinate to the individual who made the adverse benefit determination.
(3)(a) “Health insurance” means insurance providing:
(i) a health care benefit; or
(ii) payment of an incurred health care expense.
(b) Health insurance includes an accident and health insurance policy allowing for an adverse benefit determination on the basis of medical necessity, rather than a specified event.
(4)(a) “Independent review organization” means an entity that conducts independent external reviews of adverse determinations and final adverse determinations.
(b) The independent review organization chosen may 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.
(5)(a) “Medical necessity” means a health care service or product that a prudent health care professional would provide to a patient to prevent, diagnose, or treat 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.
(b) When a medical question-of-fact exists, medical necessity includes the most appropriate available supply or level of service that is known to be effective, considering potential benefits and harms to the individual in question.
(i) For an intervention not yet in widespread use, the effectiveness is based on scientific evidence.
(ii) For an established intervention, the effectiveness is based on:
(A) scientific evidence;
(B) professional standards; and
(C) expert opinion.
(6)(a) “Scientific evidence” means:
(i) a scientific study published in or accepted for publication by a medical journal that meets nationally recognized requirements for scientific manuscripts and that submits most of its published articles for review by experts who are not part of the editorial staff; or
(ii) a finding, study, or research conducted by or under the auspices of a federal government agency or nationally recognized federal research institute.
(b) Scientific evidence does not include:
(i) published peer-reviewed literature sponsored to a significant extent by a pharmaceutical manufacturing company or medical device manufacturer; or
(ii) a single study without other supportable studies.
(7)(a) “Urgent care claim” means a request for a health care service or course of treatment for which the time period for making non-urgent care request determination:
(i) could seriously jeopardize the life or health of an insured or the ability of an insured to regain maximum function; or
(ii) in the opinion of a physician with knowledge of the insured’s medical condition, would subject an insured to severe pain that cannot be adequately managed without the health care service or treatment that is the subject of the request.
(b)(i) Except as provided in Subsection (7)(a)(ii), an individual acting on behalf of a carrier shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine to determine whether a request is an urgent care claim.
(ii) If a physician with knowledge of an insured’s medical condition determines that a request is an urgent care request within the meaning of Subsection (7)(a), the request shall be treated as an urgent care claim.
R590-203-4. Adverse Benefit Determination.
ERISA-Medical Necessity Appeals-Deadlines; State Medical Necessity Appeals-Deadlines
(1) An adverse benefit determination review procedure shall comply with the adverse benefit determination review requirements set forth in 29 CFR 2560.503-1.
(2) A carrier’s adverse benefit determination appeal board or body shall include at least one consumer representative who is present at every meeting.
R590-203-5. Independent and Expedited Adverse Benefit Determination Reviews for Health Insurance.
(1) A carrier shall provide an independent review procedure as a voluntary option to resolve an adverse benefit determination of medical necessity.
(2) An independent review procedure shall be conducted by an independent review organization, person, or entity other than the carrier, 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)(a) An independent review organization is designated by the carrier or the commissioner.
(b) The independent review organization chosen may not be owned or controlled by, or exercise control with:
(i) the insurer;
(ii) the health plan;
(iii) the health plan’s fiduciary;
(iv) a national, state, or local trade association of:
(A) health insurance plans; or
(B) trade association of health care providers;
(v) the employer; or
(vi) an employee or agent of any person listed in Subsections (3)(b)(i) through (v).
(c) An independent review organization chosen may not have a material professional, familial, or financial conflict of interest with:
(i) the health plan;
(ii) an officer, director, or management employee of the health plan;
(iii) the enrollee;(iv) the enrollee’s health care provider;
(v) the health care provider’s medical group or independent practice association;
(vi) a health care facility where service would be provided; or
(vii) the developer or manufacturer of the service that would be provided.
(4) Submission to an independent review procedure is voluntary and at the discretion of the claimant.
(5)(a) A voluntary independent review procedure shall:
(i) 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;
(ii) agree that any statute of limitation or other defense based on timeliness is tolled while a voluntary appeal is pending;
(iii) 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 2560.503-1(c)(2);
(iv) upon request from a 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; and
(v) disclose that:
(A) an independent review conducted under Section 31A-22-629 and this rule may be binding on both parties; and
(B) a claimant’s submission to a binding independent review is voluntary and disclosure and notification must be given under 29 CFR 2560.503-1.
(b) If requested, the information to be provided under Subsection (5)(a)(iv) shall contain:
(i) a statement that the decision to use a voluntary level of appeal will not affect the claimant’s right to any other benefit under the plan; and
(ii) information about the applicable rules, the claimant’s right to representation, and the process for submitting an independent review.
(6) Standards for voluntary independent review:
(a) A carrier’s internal adverse benefit determination process must be exhausted unless the carrier and claimant 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) A carrier shall use the same minimum standard and notification requirement for an independent review that is used for internal levels of review, as set forth in 29 CFR 2560.503-1(h)(3), 29 CFR 2560.503-1(i)(2) and 29 CFR 2560.503-1(j).
(7) A carrier shall provide an expedited review process for urgent care claims.
(8)(a) A request for expedited review of an adverse benefit determination of medical necessity may be submitted either orally or in writing.
(b) If a request is made orally, a carrier shall send written confirmation to the claimant acknowledging the receipt of the request within 24 hours.
State Medical Necessity Appeals-Deadlines; ERISA-Medical Necessity Appeals-Deadlines
(9) An expedited review shall require a carrier to:
(a) transmit all necessary information between the plan and the claimant electronically, including the plan’s original adverse benefit determination;
(b) notify the claimant of the adverse benefit determination review, as soon as possible, considering 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) use the same minimum standard for timing and notification as set forth in 29 CFR 2560.503-1(h), 29 CFR 2560.503-1(i)(2)(i), and 29 CFR 2560.503-1(j).
R590-203-6. Disability Income Insurance Adverse Benefit Determination Review.
(1) A carrier shall notify a claimant of an adverse benefit determination review within 45 days of receipt of the claimant’s request for review of an adverse benefit determination.
(2) The time for making an adverse benefit determination review may be extended for up to 45 days if necessary due to matters beyond the carrier’s control.
(3) If the response time is extended due to the claimant’s failure to submit information necessary to decide a claim, the time for making the benefit determination on an adverse benefit determination 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 must be provided to the claimant on any adverse benefit determination free of charge.
R590-203-7. File and Record Documentation.
A carrier shall:
(1) upon request by the commissioner, make available all adverse benefit determination review files and related documentation; and
(2) maintain these records for the current calendar year plus five years.
R590-203-8. Severability.
If any provision of this rule, Rule R590-203, or its application to any person or situation is held invalid, such invalidity does not affect any other provision or application of this rule that can be given effect without the invalid provision or application. The remainder of this rule shall be given effect without the invalid provision or application.