Utah Admin. Code R590-192-7 - Notification

(1) An insurer shall notify a claimant of a benefit determination and include:

(a) the specific reason or reasons for the benefit determination;

(b) reference to the specific policy provision that the benefit determination is based upon;

(c) a description of additional information needed and an explanation of why such information is necessary; and

(d) with a notice of an adverse benefit determination:

(i) a description of the appeal procedures and any time limitations;

(ii) a description of how to initiate an appeal along with the address and telephone number;

(iii) the claimant's right to bring civil action; and

(iv) a statement regarding assistance available at the Utah Insurance Department, Office of Consumer Health Assistance.

(2)

(a) If a claimant fails to follow an insurer's procedure for filing a pre-service claim, an insurer or authorized agent shall:

(i) notify the claimant of the failure;

(ii) provide the claimant with the proper procedure to file a claim for benefits; and

(iii) provide notification to the claimant:

(A) no later than five days from the failure; or

(B) within 24 hours of the failure for a claim involving urgent care.

(b) Notification of a failure may be oral unless written notification is requested by a claimant.

(3)

(a) A notice of adverse benefit determination for a health benefit plan shall comply with Rule R590-261.

(b) Subsection (3)(a) does not apply to a grandfathered health plan defined in 45 CFR 147.140.

(4)

(a) A notice of an adverse benefit determination for income replacement insurance shall:

(i) provide the criteria relied upon in making the adverse determination; and

(ii) disclose that a copy of the criteria will be provided free of charge upon request.

(b) If an adverse benefit determination is based on medical necessity, experimental treatment, or similar exclusion or limit, an insurer shall provide either:

(i) an explanation of the scientific or clinical judgment for the determination that applies the terms of the plan to the insured's medical circumstances; or

(ii) a statement that the explanation in Subsection (3)(b)(i) will be provided free of charge upon request.

(5) An adverse benefit determination for a claim involving urgent care shall:

(a) provide written or electronic notification to the claimant no later than three days after an oral notification; and

(b) provide a description of the expedited review process applicable to each claim.

Notes

Utah Admin. Code R590-192-7

Amended by Utah State Bulletin Number 2023-17, effective 8/22/2023