§ 58-17I-15 — Expedited review decision--Notification--Required contents.

A notification of a decision under §§ 58-17I-12 to , inclusive, shall, in a manner calculated to be understood by the covered person or, if applicable, the covered person's authorized representative, set forth the following: (1) The titles and qualifying credentials of any person participating in the expedited review process (the reviewer); (2) Information sufficient to identify the claim involved with respect to the grievance, including the date of service, the health care provider, if applicable, the claim amount, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning; (3) A statement of the reviewer's understanding of the covered person's grievance; (4) The reviewer's decision in clear terms and the contract basis or medical rationale in sufficient detail for the covered person to respond further to the health carrier's position; (5) A reference to the evidence or documentation used as the basis for the decision; (6) If the decision involves a final adverse determination, the notice shall provide: (a) The specific reason or reasons for the final adverse determination, including the denial code and its corresponding meaning, as well as a description of the health carrier's standard, if any, that was used in reaching the denial; (b) A reference to the specific plan provisions on which the determination is based; (c) A description of any additional material or information necessary for the covered person to complete the request, including an explanation of why the material or information is necessary to complete the request; (d) If the health carrier relied upon an internal rule, guideline, protocol, or other similar criterion to make the adverse determination, either the specific rule, guideline, protocol, or other similar criterion or 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 upon request; (e) If the final adverse determination is based on a medical necessity or experimental or investigational treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the determination, applying the terms of the health benefit plan to the covered person's medical circumstances or a statement that an explanation will be provided to the covered person free of charge 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 adverse determination as provided in subsection (d) of this section; or (ii) The written statement of the scientific or clinical rationale for the adverse determination as provided in subsection (e) of this section; (g) A statement describing the procedures for obtaining an independent external review of the adverse determination pursuant to rules promulgated by the director; (h) A statement indicating the covered person's right to bring a civil action in a court of competent jurisdiction; (i) The following statement: "You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your state insurance director."; and (j) A notice of the covered person's right to contact the Division of Insurance for assistance at any time, including the telephone number and address of the Division of Insurance. A health carrier may provide the notice required under this section orally, in writing, or electronically. If notice of the adverse determination is provided orally, the health carrier shall provide written or electronic notice of the adverse determination within three days following the date of the oral notification. Commission Note:

Legislative History

SL 2011, ch 219, § 87.