Utah Admin. Code R590-203-5 - Independent and Expedited Adverse Benefit Determination Reviews for Health Insurance

(1) A carrier shall provide an independent review procedure as a voluntary option to resolve an adverse benefit determination of medical necessity.

(2) An independent review procedure shall be conducted by an independent review organization, person, or entity other than the carrier, the plan, the plan's fiduciary, the employer, or any employee or agent of any of the foregoing, that do not have any material professional, familial, or financial conflict of interest with the health plan, any officer, director, or management employee of the health plan, the enrollee, the enrollee's health care provider, the provider's medical group or independent practice association, the health care facility where service would be provided and the developer or manufacturer of the service being provided.

(3)

(a) An independent review organization is designated by the carrier or the commissioner.

(b) The independent review organization chosen may not be owned or controlled by, or exercise control with:

(i) the insurer;

(ii) the health plan;

(iii) the health plan's fiduciary;

(iv) a national, state, or local trade association of:

(A) health insurance plans; or

(B) trade association of health care providers;

(v) the employer; or

(vi) an employee or agent of any person listed in Subsections (3)(b)(i) through (v).

(c) An independent review organization chosen may not have a material professional, familial, or financial conflict of interest with:

(i) the health plan;

(ii) an officer, director, or management employee of the health plan;

(iii) the enrollee;

(iv) the enrollee's health care provider;

(v) the health care provider's medical group or independent practice association;

(vi) a health care facility where service would be provided; or

(vii) the developer or manufacturer of the service that would be provided.

(4) Submission to an independent review procedure is voluntary and at the discretion of the claimant.

(5)

(a) A voluntary independent review procedure shall:

(i) waive any right to assert that a claimant has failed to exhaust administrative remedies because the claimant did not elect to submit a dispute of medical necessity to a voluntary level of appeal provided by the plan;

(ii) agree that any statute of limitation or other defense based on timeliness is tolled while a voluntary appeal is pending;

(iii) allow a claimant to submit a dispute of medical necessity to a voluntary level of appeal only after exhaustion of the appeals permitted under 29 CFR 2560.503-1(c)(2);

(iv) upon request from a claimant, provide sufficient information relating to the voluntary level of appeal to enable the claimant to make an informed decision about whether to submit a dispute of medical necessity to the voluntary level of appeal; and

(v) disclose that:

(A) an independent review conducted under Section 31A-22-629 and this rule may be binding on both parties ; and

(B) a claimant's submission to a binding independent review is voluntary and disclosure and notification must be given under 29 CFR 2560.503-1.

(b) If requested, the information to be provided under Subsection (5)(a)(iv) shall contain:

(i) a statement that the decision to use a voluntary level of appeal will not affect the claimant's right to any other benefit under the plan; and

(ii) information about the applicable rules, the claimant's right to representation, and the process for submitting an independent review.

(6) Standards for voluntary independent review:

(a) A carrier's internal adverse benefit determination process must be exhausted unless the carrier and claimant agree to waive the internal process.

(b) Any adverse benefit determination of medical necessity may be the subject of an independent review.

(c) The claimant has 180 calendar days from the date of the final internal review decision to request an independent revi e w.

(d) A carrier shall use the same minimum standard and notification requirement for an independent review that is used for internal levels of review, as set forth in 29 CFR 2560.503-1(h)(3), 29 CFR 2560.503-1(i)(2) and 29 CFR 2560.503-1(j).

(7) A carrier shall provide an expedited review process for urgent care claims.

(8)

(a) A request for expedited review of an adverse benefit determination of medical necessity may be submitted either orally or in writing.

(b) If a request is made orally, a carrier shall send written confirmation to the claimant acknowledging the receipt of the request within 24 hours.

(9) An expedited review shall require a carrier to:

(a) transmit all necessary information between the plan and the claimant electronically, including the plan's original adverse benefit determination;

(b) notify the claimant of the adverse benefit determination review, as soon as possible, considering the medical urgency, but not later than 72 hours after receipt of the claimant's request for review of an adverse benefit determination; and

(c) use the same minimum standard for timing and notification as set forth in 29 CFR 2560.503-1(h), 29 CFR 2560.503-1(i)(2)(i), and 29 CFR 2560.503-1(j).

Notes

Utah Admin. Code R590-203-5

Amended by Utah State Bulletin Number 2022-12, effective 5/26/2022