02-031 C.M.R. ch. 425, § 32 - Appealing a Claims Denial

Current through 2022-14, April 6, 2022

A. Representation. For purposes of this section and for section 33, "insured" includes the insured's authorized representative.
B. Notice. An insurer shall provide clear written notice to the insured of any claims denial. The notice shall include:
(1) The reason or reasons for the decision;
(2) Reference to the specific contract provision on which the decision is based;
(3) A description of any additional material or information necessary for the insured to perfect the claim and an explanation of why such material or information is necessary;
(4) The insured's right to internal appeal in accordance with subsection C, including instructions and time limits for initiating the appeal, and the right to submit new or additional information relating to the claims denial with the appeal request;
(5) The insured's right, after completion of the insurer's internal appeal process, to have the claims denialreviewed under the independent review process in accordance with Section 33 if the claims denial is eligible for external review, and the right to file a complaint with the superintendent after completion of at least one level of the insurer's internal review process.
C. Standard Appeal. The insured may appeal the claimsdenial by sending a written request to the insurerwithin 120 days after receipt of the claims denialalong with any additional supporting information. The internal appeal shall be considered by apanel of one or more qualified individuals, designated by the insurer, who did not participate in making the initial benefit determination.
(1) Timeline for Appeal. The internal appeal shall be completed and written notice of the internal appeal decision shall be sent to the insured within thirty (30) calendar days after the insurer's receipt of all necessary information upon which a final determination can be made. Additional time is permitted when the insurer can establish the 30-day time frame cannot reasonably be met due to the insurer's inability to obtain necessary information from a person not affiliated with or under contract with the insurer. The insurer shall provide written notice of the delay to the insured. In such instances, decisions must be issued within 30 days after the insurer's receipt of all necessary information.
(2) Notice of Decision. If the claims denial appeal decision is adverse to the insured, the written decision shall contain:
(a) The qualifying credentials of the person or persons evaluating the appeal;
(b) A statement of the reviewers' understanding of the reason for the insured's request for an appeal;
(c) Reference to the specific policy provisions upon which the decision is based;
(d) The reviewers' decision in clear terms and the rationale in sufficient detail for the insured to respond further to the insurer's position;
(e) A reference to the evidence or documentation used as the basis for the decision, including any clinical review criteria used to make the determination. The decision shall include instructions for requesting copies, free of charge, of information relevant to the claim, including any referenced evidence, documentation, or clinical review criteria not previously provided to the insured.
(f) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the claims denial decision, either the specific rule, guideline, protocol or other similar criterion that was relied upon in making the claims denial decision or an explanation that a copy will be provided free of charge to the insured upon request;
(g) Notice of any subsequent appeal rights and the procedure and time limitation for exercising those rights. Notice of external review rights must be provided for decisions on claimsdenials eligible for external review.
(h) Notice of the insured's right to contact the superintendent's office. The notice shall contain the toll free telephone number, website address and mailing address of the bureau.
D. Second Level Review
(1) An insurer shall provide a second level appeal process to an insured who is dissatisfied with a first level review determination under Subsection C. The insured has the right to appear before authorized representatives of the insurer and shall be provided adequate notice of that option by the insurer. The insured may appeal the standard appeal decision by sending a written request to the insurer within 120 days after receipt of the standard appeal decision letter.
(2) The insurer shall appoint a second level appeal review panel for each appeal subject to review under this subsection. A majority of the panel shall consist of employees or representatives of the insurer who were not previously involved in the appeal.
(3) If an insured initiates a second level appeal without requesting to appear before authorized representatives of the insurer, the second level appeal shall be completed and written notice of the final internal appeal decision shall be sent to the insured within thirty (30) calendar days after the insurer's receipt of all necessary information upon which a final determination can be made. Additional time is permitted when the insurer can establish that the 30-day time frame cannot reasonably be met due to the insurer's inability to obtain necessary information from a person not affiliated with or under contract with the insurer. The insurer shall provide written notice of the delay to the insured. In such instances, decisions must be issued within 30 days after the insurer's receipt of all necessary information. A decision adverse to the insured shall include the information specified in Subparagraph C(2).
(4) Whenever an insured has requested the opportunity to appear before authorized representatives of the insurer, an insurer's procedures for conducting a second level panel review shall include the following:
(a) The review panel shall schedule and hold a review meeting within 45 days after receiving a request from the insured for a second level review. The review meeting shall be held at a time reasonably accessible to the insured. The insurer shall offer the insured the opportunity to appear before the review panel, at the insurer's expense, by conference call, video conferencing, or other appropriate technology. The insured shall be notified in writing at least 15 days in advance of the review date. The insurer shall not unreasonably deny a request for postponement of the review made by the insured.
(b) Upon the request of an insured, the insurer shall provide to the insured, free of charge, all relevant information that is not confidential and privileged from disclosure to the insured.
(c) The insured has the right to:
i) Attend the second level review by conference call, video conferencing, or other appropriate technology;
ii) Present his or her case to the review panel;
iii) Submit supporting material both before and at the review meeting;
iv) Ask questions of any representative of the insurer who has provided information to the panel; and
v) Be assisted or represented by a person of his or her choice.
(d) If the insurer will have an attorney present to argue its case against the insured, the insurer shall so notify the insured at least 15 days in advance of the review and shall advise the insured of his or her right to obtain legal representation.
(e) The insured's right to a fair review shall not be made conditional on his or her appearance at the review.
(f) The review panel shall issue a written decision to the insured within 5 working days after completing the review meeting. A decision adverse to the insured shall include the information specified in Subparagraph C(2).

Notes

02-031 C.M.R. ch. 425, § 32

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