Utah Admin. Code R590-192-8 - Minimum Standards for Prompt, Fair, and Equitable Benefit Determination and Settlement

(1)

(a) A benefit determination time period begins once an insurer receives a claim, regardless of whether all necessary information was filed with the original claim.

(b) If an insurer requires an extension due to a claimant's failure to submit necessary information, the time period for making a decision is tolled from the date the notice is sent to the claimant through:

(i) the date the claimant provides the necessary information; or

(ii) 48 hours after the end of the time period for the claimant to provide the additional information.

(2)

(a) When a claim involves urgent care, an insurer shall notify a claimant of the insurer's benefit decision as soon as possible, considering the medical exigencies of the situation, but no later than 72 hours after receipt of the claim.

(b) An insurer shall determine whether a claim is urgent based on the information provided by the claimant.

(c) If a claimant does not provide sufficient information for an insurer to make a decision, the insurer must notify the claimant as soon as possible, but not later than 24 hours after receipt of the claim, and specify the information that is required.

(d) A claimant shall be given reasonable time, but not less than 48 hours, to provide the required information.

(e) An insurer shall notify a claimant of the insurer's decision as soon as possible, but not later than 48 hours after the earlier of:

(i) the insurer's receipt of the requested information; or

(ii) the end of the time given to the claimant to provide the information.

(3)

(a) A reduction or termination of concurrent care during treatment is considered an adverse benefit determination.

(b) Before a reduction or termination of concurrent care occurs, an insurer shall provide a claimant notice, with sufficient time to appeal and receive a decision on the adverse benefit determination.

(c)

(i) A claimant may request an extension of concurrent care beyond what is approved.

(ii) If a request for an extension is made at least 24 hours before the end of the concurrent care, the insurer shall notify the claimant of the insurer's decision as soon as possible, but not later than 24 hours after receipt of the request.

(iii) If the request for extension does not involve urgent care, the insurer shall notify the claimant of the insurer's benefit decision using the response times for a post-service claim.

(4)

(a) An insurer shall notify a claimant of the insurer's pre-service benefit decision within 15 days of receipt of the request for care.

(b)

(i) If an insurer cannot make a decision within 15 days due to circumstances beyond the insurer's control, such as late receipt of medical records, the insurer may extend the time up to 15 additional days.

(ii) If an insurer chooses to extend up to 15 days, the insurer shall notify the claimant before the expiration of the original 15 days.

(c) If an extension is due to a claimant's failure to submit necessary information, the notice of extension shall:

(i) state what information the claimant must submit; and

(ii) give the claimant at least 45 days to submit the requested information.

(d) If a pre-service claim determination is made and the medical care is rendered, the claim shall be processed according to the time requirements of a post-service claim.

(5)

(a) For a post-service claim, an insurer shall notify a claimant of the insurer's benefit decision within 30 days of receipt of a notice of loss.

(b)

(i) If an insurer is unable to make a decision within 30 days due to circumstances beyond the insurer's control, such as late receipt of medical records, the insurer may extend the time up to 15 additional days.

(ii) If an insurer chooses to extend up to 15 days, the insurer shall notify the claimant before the expiration of the original 30 days.

(c) If an extension is due to a claimant's failure to submit necessary information, the notice of extension shall:

(i) state what information the claimant must submit; and

(ii) give the claimant at least 45 days to submit the requested information.

(6) An insurer offering a health benefit plan shall provide continued coverage for an ongoing course of treatment pending the outcome of an internal appeal.

(7) Except for a grandfathered individual health benefit plan as defined in 45 CFR 147.140, an insurer offering an individual health benefit plan shall provide only one level of internal appeal before the final determination is made.

Notes

Utah Admin. Code R590-192-8

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