Reviews of grievances involving an adverse determination
See bold text below:
(a) A covered person or the covered person’s authorized representative may file a grievance with a health care insurer requesting a review of an adverse determination. The covered person or the covered person’s authorized representative shall file the request not later than 180 days after the covered person or the covered person’s authorized representative received notice of the adverse determination under 3 AAC 28.900 – 3 AAC 28.918. The health care insurer shall extend the 180-day time period for filing a request if the
(1) covered person or the covered person’s authorized representative files a request with the health care insurer seeking an extension; and
(2) the written request for the extension sets out one or more justifications for the extension that a prudent person would consider to be a fair and reasonable basis for allowing the extension; the covered person or the covered person’s authorized representative does not need to file the request for an extension under this subsection within the 180-day filing period.
(b) Upon receipt of the grievance filed under (a) of this section, a health care insurer shall provide to the covered person or the covered person’s authorized representative the name, address, and telephone number of the person or organizational unit designated by the health care insurer to coordinate the review on behalf of the health care insurer.
(c) For a review conducted under this section, a health care insurer shall ensure the independence and impartiality of each individual involved in making the review decision.
(d) A health care insurer may not base one or more of the following decisions related to an individual involved in making a review decision on the likelihood that the individual will support the denial of benefits:
(1) hiring;
(2) compensation;
(3) termination;
(4) promotion; or
(5) other similar matter.
(e) In an adverse determination involving utilization review, a health care insurer shall designate an appropriate clinical peer or peers, of the same or similar specialty as would typically manage the case being reviewed, to review the adverse determination. A health care insurer may not designate a person involved in the initial adverse determination to be a clinical peer.
(f) If more than one clinical peer is designated under (e) of this section, a health care insurer shall ensure that a majority of those designated are health care professionals who have appropriate expertise.
(g) In conducting a review under this section, a reviewer shall consider all comments, documents, records, and other information regarding the request for services submitted by a covered person or the covered person’s authorized representative, without regard to whether the information was submitted or considered in making the initial adverse determination.
(h) A covered person or the covered person’s authorized representative
(1) does not have the right to attend the review;
(2) may submit written comments, documents, records, and other materials relating to the request for benefits for consideration during the review; and
(3) may receive from a health care insurer, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the covered person’s request for benefits; in this paragraph, “relevant” means a document, record, or other information that
(A) was relied upon in making the benefit determination;
(B) was submitted, considered, or generated in the course of making the adverse determination, without regard to whether the document, record, or other information was relied upon in making the benefit determination;
(C) demonstrates that, in making the benefit determination, the health care insurer or its designated representatives consistently applied required administrative procedures and safeguards with respect to the covered person as other similarly situated covered persons; or
(D) constitutes a statement of policy or guidance with respect to the health care insurance policy concerning the denied health care service or treatment for the covered person’s diagnosis, without regard to whether the advice or statement was relied upon in making the benefit determination.
(i) Not later than three working days after receiving a grievance, a health care insurer shall provide a covered person or the covered person’s authorized representative with notice of the provisions of this section.
(j) The time period within which a decision is required to be made and notice provided under (k) and (l) of this section begins on the date the grievance is filed with a health care insurer under the health care insurer’s procedures established under 3 AAC 28.934 for filing a request, without regard to whether all of the information necessary to make the determination accompanies the filing. A health care insurer shall notify and issue a decision in writing or by electronic mail to the covered person or the covered person’s authorized representative not later than the time frames required under (k) or (l) of this section.
Medical Necessity Appeals-Deadlines
(k) With respect to a grievance of an adverse determination involving a prospective review request, a health care insurer shall notify, and issue a decision to, the covered person or the covered person’s authorized representative within a reasonable period of time that is appropriate given the covered person’s medical condition, but not later than 30 days after the date the health care insurer received the grievance under (a) of this section.
(l) With respect to a grievance requesting a review of an adverse determination involving a retrospective review request, a health care insurer shall notify, and issue a decision to, the covered person or the covered person’s authorized representative within a reasonable period of time but not later than 30 days after the date the health care insurer received the grievance under (a) of this section.
(m) Before issuing a decision under (k) or (l) of this section, a health care insurer shall provide free of charge to the covered person or the covered person’s authorized representative new or additional evidence relied upon in connection with the grievance, sufficiently in advance of the date the decision is required to be provided, to permit a covered person or the covered person’s authorized representative a reasonable opportunity to respond before that date.
(n) Before issuing or providing notice of a final adverse determination under (k) or (l) of this section that is based on a new or additional rationale, a health care insurer shall provide the new or additional rationale to the covered person or the covered person’s authorized representative free of charge and as soon as possible, sufficiently in advance of the date when the notice of final adverse determination is to be provided, to permit a covered person or the covered person’s authorized representative a reasonable opportunity to respond before that date.
(o) Notice of a decision issued under (k) or (l) of 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) the name, title, and qualifying credentials of each person participating as a reviewer in the review process;
(2) information sufficient to identify the claim involved with respect to the grievance, including the date of service, if applicable, the health care provider, and, if applicable, the claim amount;
(3) a statement describing the
(A) diagnosis code and the code’s corresponding meaning; and
(B) treatment code and the code’s corresponding meaning;
(4) a statement of the reviewers’ understanding of the covered person’s grievance;
(5) the reviewers’ decision, which must include
(A) clear terms;
(B) the contract basis or medical rationale in sufficient detail for a covered person or the covered person’s authorized representative to respond further to the health care insurer’s position;
(6) a reference to the evidence or documentation used as the basis for the decision;
(7) if the decision issued under (k) or (l) of this section upholds the adverse determination, the notice must include
(A) the specific reason or reasons for the final adverse determination including
(i) the denial code and the code’s corresponding meaning; and
(ii) a description of the health care insurer’s standard, if any, used in reaching the denial;
(B) reference to the specific plan provisions on which the determination is based;
(C) a statement that a covered person or the covered person’s authorized representative 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 covered person’s benefit request; in this subparagraph, “relevant” has the meaning given in (h)(3) of this section;
(D) if a health care insurer relied upon an internal rule, guideline, protocol, or other similar criterion to make the final adverse determination,
(i) the specific rule, guideline, protocol, or other similar criterion; or
(ii) a statement that a copy of the rule, guideline, protocol, or other similar criterion was relied upon to make the final 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;
(E) if a final adverse determination is based on a medical necessity or experimental or investigational treatment, or similar exclusion or limit,
(i) 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
(ii) a statement that an explanation will be provided free of charge to the covered person or the covered person’s authorized representative 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 final adverse determination under (D) of this paragraph; and
(ii) the written statement of the scientific or clinical rationale for the determination under (E) of this paragraph;
(G) a statement describing the procedures for obtaining an independent external review of the adverse determination under 3 AAC 28.950 – 3 AAC 28.982;
(H) a statement indicating a covered person’s right to bring a civil action in superior court; and
(I) a statement of a covered person’s or covered person’s authorized representative’s right to contact the director’s office for assistance with respect to a claim, grievance, or appeal at any time; the statement must include the division’s current mailing address, electronic mail address, and telephone number.
(p) A health care insurer shall provide the notice required under (o) 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).
(q) To meet the requirements of (p) 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.