02-031 C.M.R. ch. 425, § 33 - External Review

Current through 2022-14, April 6, 2022

A. Notice of External Review. If the insurer's claims denial eligible for external reviewis upheld after completion of the insurer's internal appeal process outlined in section 32, the insurer shall provide a written description of the insured's right to request an external review. The notice must include:

(1) A description of the externalreview procedure and the requirements for making a request for external review;

(2) A statement informing the insured how to request assistance from the insurer in filing a request for external review;

(3) A statement informing the insured of the right to participatein the external review proceeding by teleconference or other reasonable means, to obtain and submit material in support of the claim, to ask questions of the insurer, and to have outside assistance; and

(4) A statement informing the insured of the right to seek assistance or file a complaint with the bureau and the toll-free number for the bureau.

B. Request. The insured may request an externalreview of the claims denial eligible for external reviewafter completion of both levels of the insurer's internal appeal process outlined inSection 32. A written request for externalreview may be made by the insured to the bureau within 120days after the insurer's written notice of the final internal appeal decision is received by the insured. The insured may not be required to pay any filing fee as a condition of processing a request for external review.

C. Cost. The cost of the external review shall be borne by the insurer.

D. Insured's Right to Alternative Formats. The insurer shall provide auxiliary telecommunications devices or qualified interpreter services by a person proficient in American Sign Language, when requested by an insured who is deaf or hard-of-hearing;shall provide printed materials in an accessible format, including Braille, large-print materials, computer diskette, audio cassette or a reader, when requested by an insured who is visually impaired; and shall makesuch other reasonable accommodations as may be necessary to allow an insured to exercise the right to external review under this section.

E. Bureau Oversight. The bureau shall oversee the external review process and shall contract with approved independent review organizations to conduct external reviews and render external review decisions. At a minimum, an independent review organization approved by the bureau shall ensure the selection of qualified and impartial reviewers who have no professional, familial, or financial conflict of interest relating to the insurer, the insured, or the insured's authorized representative or long-term care provider involved in the external review.

F. Independent External Review Decision; Timelines. An external review decision must be made in accordance with the following requirements.

(1) In rendering an external review decision, the independent review organization must give consideration to the following:

(a) All relevant clinical information relating to the insured's physical and mental condition, including any competing clinical information;

(b) All relevant clinical standards and guidelines, including, but not limited to, those standards and guidelines relied upon by the insurer.

(2) If the independent review organization rules in favor of the claimant in a dispute arising out of a federally tax-qualified contract, it shall provide a certification by a licensed health care practitioner (as defined in Section 7702B(c)(4) of the Internal Revenue Code) that the insured is chronically ill.

(3) An external review decision must be rendered by an independent review organization within 30 days of receipt of a completed request for external review from the bureau.

(4) Binding nature of decision. An external review decision is binding on the insurer. An insured may not file a request for a subsequent external review involving the same claims denial for which the insured has already received an external review decision pursuant to this section. An external review decision made under this section is not considered final agency action pursuant to Title 5, chapter 375, subchapter II.

G. Additional Rights. Nothing contained in this section shall limit the ability of an insurer to assert any rights an insurer may have under the policy related to:

(1) An insured's misrepresentation;

(2) Changes in the insured's benefit eligibility; and

(3) Terms, conditions, and exclusions of the policy, other than the failure to meet the requirements to pay theclaim.

H. Long-Term Care Insurance Independent Review Organizations. The superintendent shall contract with qualified long-term care insurance independent review organizations. To be considered qualified, an organization must meet the following criteria:

(1) Have on staff, or contract with, a qualified and licensed health care professional in an appropriate field for determining an insured's functional or cognitive impairment (e.g., physical therapy, occupational therapy, neurology, physical medicine and rehabilitation), to conduct the review.

(2) Neither it nor any of its licensed health care professionals may, in any manner, be related to or affiliated with a person or entity that previously provided medical care to the insured.

(3) Utilize a licensed health care professional who is not an employee of the insurer or related in any manner to the insured.

(4) Neither it nor its licensed health care professional who conducts the reviews may receive compensation of any type that is dependent on the outcome of the review.

(5) Provide a description of the fees it charges for externalreviews of a long-term care insurance adverse benefit determination. Such fees shall be reasonable and customary for the type of long-term care insurance adverse benefit determination under review.

(6) Provide the name of the medical director or health care professional responsible for the supervision and oversight of the externalreview procedure.

(7) Have on staff or contract with a licensed health care practitioner, who is qualified to certify that an individual is chronically ill for purposes of a qualified long-term care insurance contract.

(Drafting Note: Although this section does not apply to contracts issued or issued for delivery in other states even if the insured becomes a resident of this state, insurers are encouraged to voluntarily adopt these standards for insureds who obtain long-term care services in this state. Nothing in this rule prohibits insurers from voluntarily complying with this section.)

Notes

02-031 C.M.R. ch. 425, § 33