. If the insurer's claims denial eligible for external
reviewis upheld after completion of the insurer's internal appeal process
outlined in section
, 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
(2) A statement informing
the insured how to request assistance from the insurer in filing a request for
(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
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.
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
. 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.
Cost. The cost of the
external review shall be borne by the insurer.
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.
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
External Review Decision; Timelines
. An external review decision must be
made in accordance with the following requirements.
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;
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.
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
. 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
conditions, and exclusions of the policy, other than the failure to meet the
requirements to pay theclaim.
Long-Term Care Insurance Independent
. 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
(3) Utilize a licensed
health care professional who is not an employee of the insurer or related in
any manner to the insured.
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
(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
(6) Provide the name of the
medical director or health care professional responsible for the supervision
and oversight of the externalreview procedure.
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.)