§ 58-17H-19 — Determinations to be issued in timely manner--Process to ensure consistency.

A health carrier shall issue utilization review and benefit determinations in a timely manner pursuant to the requirements of §§ 58-17H-27 to 58-17H-32 , inclusive, and §§ 58-17H-40 to 58-17H-48 , inclusive. A health carrier shall have a process to ensure that utilization reviewers apply clinical review criteria in conducting utilization review consistently. If a health carrier fails to strictly adhere to the requirements of §§ 58-17H-27 to 58-17H-32 , inclusive, and §§ 58-17H-40 to 58-17H-48 , inclusive, with respect to making utilization review and benefit determinations of a benefit request or claim, the covered person shall be deemed to have exhausted the provisions of chapters 58-17G and 58-17H , and may take action regardless of whether the health carrier asserts that the carrier substantially complied with the requirements of §§ 58-17H-27 to 58-17H-32 , inclusive, and §§ 58-17H-40 to 58-17H-48 , inclusive, as applicable, or that any error it committed was de minimus. Any covered person may file a request for external review in accordance with rules promulgated by the director. In addition to the external review rights a covered person is entitled to pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal claims and appeals process that would yield a decision on the merits of the claim. Commission Note:

Legislative History

SL 2011, ch 219, § 44.