Retrospective review determinations–Timing–Notification requirements
For retrospective review determinations, the health carrier shall make the determination within a reasonable period of time, but in no event later than thirty days after the date of receiving the benefit request.
In the case of a certification, the health carrier may notify in writing the covered person and the provider rendering the service.
If the determination is an adverse determination, the health carrier shall provide notice of the adverse determination to the covered person or, if applicable, the covered person’s authorized representative, in accordance with § 58-17H-32 The time period for making a determination and notifying the covered person or, if applicable, the covered person’s authorized representative, of the determination pursuant to this section may be extended once by the health carrier for up to fifteen days, if the health carrier:
(1) Determines that an extension is necessary due to matters beyond the health carrier’s control; and
(2) Notifies the covered person or, if applicable, the covered person’s authorized representative, prior to the expiration of the initial thirty-day time period, of the circumstances requiring the extension of time and the date by which the health carrier expects to make a determination.
If the extension under this section is necessary due to the failure of the covered person or, if applicable, the covered person’s authorized representative to submit information necessary to reach a determination on the request, the notice of extension shall specifically describe the required information necessary to complete the request and give the covered person or, if applicable, the covered person’s authorized representative at least forty-five days from the date of receipt of the notice to provide the specified information. (SL 2012, ch 239, § 1 provides: “The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.”)