Procedures for standard utilization review and benefit determinations
See bold text below:
(a) A health care insurer shall establish and maintain written procedures for
(1) receiving a benefit request from a covered person or the covered person’s authorized representative;
(2) making a standard utilization review and benefit determination; and
(3) notifying a covered person or the covered person’s authorized representative of the health care insurer’s determination not later than the specified time frames required under this section.
Medical Necessity Decisions-Deadlines
(b) For a prospective review determination, a health care insurer shall make the determination and notify the covered person or the covered person’s authorized representative of the determination, whether the health care insurer certifies the provision of the benefit or not, within a reasonable period of time appropriate to the covered person’s medical condition, but not later than five working days after the date the health care insurer receives the request. If the determination is an adverse determination, the health care insurer shall make the notification of the adverse determination under (n) – (t) of this section.
(c) The time period for making a determination and notifying the covered person or the covered person’s authorized representative under (b) of this section may be extended one time by a health care insurer for not later than five working days, if the health care insurer
(1) determines that an extension is necessary due to matters beyond the health care insurer’s control; and
(2) notifies the covered person or the covered person’s authorized representative, before the expiration of the initial five-working-day time period, of
(A) the circumstances requiring the extension of time; and
(B) the date by which the health care insurer expects to make a determination.
(d) If the extension under (c) of this section is due to the failure of the covered person or the covered person’s authorized representative to submit the information necessary to reach a determination on the request, the notice of extension must
(1) specifically describe the required information necessary to complete the request; and
(2) give the covered person or the covered person’s authorized representative not less than 45 days from the date of receipt of the notice of extension to provide the specified information.
(e) As soon as possible, but not later than five working days after receiving from a covered person or a covered person’s authorized representative a prospective review request that fails to meet the health care insurer’s filing procedures, a health care insurer shall notify the covered person or the covered person’s authorized representative
(1) of the failure to meet the health care insurer’s filing procedures; and
(2) of the proper procedures for filing a request.
(f) A health care insurer may provide the notice under (e) of this section orally or, if requested by the covered person or the covered person’s authorized representative, in writing.
(g) The provisions of (e) and (f) of this section apply only if the failure is a communication
(1) by a covered person or a covered person’s authorized representative that is received by a person or organizational unit of a health care insurer responsible for handling benefit matters; and
(2) that refers to a specific
(A) covered person;
(B) medical condition or symptom; and
(C) health care service, treatment, or provider for which certification is being requested.
Medical Necessity Decisions-Deadlines
(h) For a concurrent review determination, if a health care insurer has certified an ongoing course of treatment to be provided over a period of time or number of treatments,
(1) a benefit reduction or termination by the health care insurer during the course of treatment before the end of the period or number of treatments, other than by health care insurance policy amendment or termination of the health care insurance policy, constitutes an adverse determination;
(2) the health care insurer shall notify the covered person or the covered person’s authorized representative under (n) – (t) of this section sufficiently in advance of the benefit reduction or termination to allow the covered person or the covered person’s authorized representative to
(A) file a grievance to request a review of the adverse determination under 3 AAC 28.930 – 3 AAC 28.938; and
(B) obtain a determination with respect to that review of the adverse determination before the benefit is reduced or terminated; and
(3) the health care insurer shall continue without liability to the covered person, with respect to the internal review request made under 3 AAC 28.930 – 3 AAC 28.938, the health care service or treatment that is the subject of the adverse determination.
Medical Necessity Decisions-Deadlines
(i) For a retrospective review determination, a health care insurer shall make the determination within a reasonable period of time, but not later than 30 days after receiving the benefit request. If the determination is an adverse determination, a health care insurer shall provide the notice of the adverse determination to the covered person or the covered person’s authorized representative under (n) – (t) of this section.
(j) The time period for making a determination and notifying the covered person or the covered person’s authorized representative under (i) of this section may be extended one time by a health care insurer for not later than 15 days if the health care insurer
(1) documents that an extension is necessary due to matters beyond the health care insurer’s control; and
(2) notifies the covered person or the covered person’s authorized representative, before the expiration of the initial 30-day time period, of
(A) the circumstances requiring the extension of time; and
(B) the date by which the health care insurer expects to make a determination.
(k) If the extension under (j) of this section is due to the failure of the covered person or the covered person’s authorized representative to submit the information necessary to reach a determination on the request, the notice of extension must
(1) specifically describe the required information necessary to complete the request; and
(2) give the covered person or the covered person’s authorized representative not less than 45 days from the date of receipt of the notice of extension to provide the specified information.
(l) The time period within which a determination is required to be made under (b) or (i) of this section begins on the date the request is filed with a health care insurer under the health care insurer’s procedures established under 3 AAC 28.906 for filing a request, without regard to whether all of the information necessary to make the determination accompanies the filing. If the time period for making the determination under (b) or (i) of this section is extended under (c) or (j) of this section, a health care insurer may not include, in the time period for making the determination, the date on which the health care insurer sends notification of the extension to the covered person or the covered person’s authorized representative until the earlier of the date on which the
(1) covered person or the covered person’s authorized representative responds to the request for additional information; or
(2) specified information was to have been submitted.
(m) If the covered person or the covered person’s authorized representative fails to submit the information before the end of the period of the extension under (d) or (k) of this section, a health care insurer may deny the certification of the requested benefit.
(n) A notification of an adverse determination under this section must be set out in a manner calculated to be understood by a person who has an average knowledge of health and medicine and must include
(1) information sufficient to identify the benefit request or claim involved, including, if applicable, the date of service, the health care provider, and, if applicable, the claim amount;
(2) a statement describing
(A) the diagnosis code and the code’s corresponding meaning; and
(B) the treatment code and the code’s corresponding meaning;
(3) the specific reason or reasons for the adverse determination, including
(A) the denial code and code’s corresponding meaning; and
(B) a description of the health care insurer’s standard, if any, used in denying the benefit request or claim;
(4) reference to the specific plan provisions on which the determination is based;
(5) a description of additional material or information necessary for the covered person or the covered person’s authorized representative to complete the benefit request, including an explanation of why the material or information is necessary to complete the request;
(6) a description of the health care insurer’s grievance procedures established under 3 AAC 28.930 – 3 AAC 28.938, including time limits, if any, applicable to those procedures;
(7) if the health care insurer relied upon an internal rule, guideline, protocol, or other similar criterion to make the adverse determination,
(A) the specific rule, guideline, protocol, or other similar criterion; or
(B) 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 or the covered person’s authorized representative upon request;
(8) if the adverse determination is based on a medical necessity or experimental or investigational treatment, or similar exclusion or limit,
(A) an explanation of the scientific or clinical judgment for making the determination, applying the terms of the health care insurance policy to the covered person’s medical circumstances; or
(B) a statement that an explanation will be provided free of charge to the covered person or the covered person’s authorized representative 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 under (7) of this subsection; or
(B) the written statement of the scientific or clinical rationale for the determination under (8) of this subsection; and
(10) a statement explaining the availability of, and the right of, the covered person or the covered person’s authorized representative to
(A) contact the division for assistance; the statement must include the division’s current mailing address, electronic mail address, and telephone number; or
(B) upon completion of a health care insurer’s grievance procedure process under 3 AAC 28.930 – 3 AAC 28.938, file a civil suit in superior court.
(o) A health care insurer shall provide the notice required under (n) of this section in a culturally and linguistically appropriate manner under whichever of the following federal regulations is applicable to the health care insurer’s notice:
(1) 29 C.F.R. 2590.715-2719(e);
(2) 45 C.F.R. 147.136(e).
(p) To meet the requirements of (o) of this section, a health care insurer shall
(1) provide oral language services, such as a telephone assistance hotline, that include, in the applicable non-English language,
(A) answering questions; and
(B) providing assistance with filing
(i) benefit requests;
(ii) claims; and
(iii) appeals;
(2) provide, upon request, a notice in the applicable non-English language; and
(3) include in the English version of all notices, a statement prominently displayed in the applicable non-English language clearly indicating how to access the language services provided by the health care insurer.
(q) For purposes of (p) of this section, with respect to a borough equivalent to which a notice is sent, a non-English language is an applicable non-English language if 10 percent or more of the population residing in the borough equivalent is literate only in the same non-English language, as determined in CLAS County Data, Edition Date: January 2016, issued by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, on January 27, 2016, and adopted by reference.
Retroactive Denial
(r) A health care insurer offering group or individual health insurance coverage may not rescind coverage under the health care insurance policy, certificate of coverage, or contract of insurance, with respect to an individual, including a group to which the individual belongs or family coverage in which the individual is included, once the individual is covered under the plan or coverage, unless
(1) the individual or person seeking coverage on behalf of the individual
(A) performs an act, practice, or omission that constitutes fraud; or
(B) makes an intentional misrepresentation of material fact, as prohibited by the terms of the plan or coverage; and
(2) the health care insurer provides not less than 30 days’ advance written notice to each participant, including a primary subscriber in the individual market, who would be affected before coverage may be rescinded.
(s) If the adverse decision is a rescission, a health care insurer shall provide in the advance notice of the rescission determination required under (r) of this section, in addition to the applicable disclosures required under (n) of this section,
(1) a clear identification of the
(A) alleged fraudulent act, practice, or omission; or
(B) intentional misrepresentation of material fact;
(2) an explanation as to why the act, practice, or omission was fraudulent or was an intentional misrepresentation of a material fact;
(3) notice that the covered person or the covered person’s authorized representative, before the date when the advance notice of the proposed rescission ends, may immediately file a grievance under 3 AAC 28.930 – 3 AAC 28.938 to request a review of the adverse determination to rescind coverage;
(4) a description of the health care insurer’s grievance procedures established under 3 AAC 28.930 – 3 AAC 28.938, including time limits, if any, applicable to those procedures; and
(5) the date when the advance notice ends and the date back to which the coverage will be retroactively rescinded.
(t) A health care insurer may provide a notice required under this section in writing, by electronic mail, or orally. If the notice of the adverse determination is provided orally, the health care insurer shall provide written or electronic mail notice of the adverse decision not later than three days following the oral notification.