Utah Admin. Code R590-261-10 - Expedited Independent Review

(1) An expedited independent review process shall be available if the adverse benefit determination:

(a) involves an insured's medical condition that may seriously jeopardize the life or health of the insured or the insured's ability to regain maximum function;

(b) may, in the opinion of the insured's attending provider, subject the insured to severe pain that cannot be adequately managed without the care or treatment that is the subject of the adverse benefit determination; or

(c) involves an admission, availability of care, continued stay, or health care service for which the insured received emergency medical services, but has not been discharged from a facility.

(2)

(a) Upon receiving a request for an expedited independent review, the commissioner shall immediately send a copy of the request to the carrier for an eligibility review.

(b) Immediately upon receiving the request, the carrier shall determine if:

(i) the individual was an insured in the health benefit plan at the time the health care service was requested or provided;

(ii) the health care service is a covered benefit; and

(iii) the claimant provided the information and forms required to process an expedited independent review.

(c)

(i) The carrier shall immediately notify the claimant and the commissioner if:

(A) the request is complete; and

(B) the request is eligible for an expedited independent review.

(ii) If the request is not complete, the carrier shall inform the claimant and the commissioner, in writing, of the information or materials needed to make the request complete.

(iii) If the request is not eligible for an expedited independent review, the carrier shall:

(A) inform the claimant and the commissioner, in writing, of the reasons for ineligibility; and

(B) inform the claimant that the determination may be appealed to the commissioner.

(d)

(i) The commissioner may determine that a request is eligible for an expedited independent review, notwithstanding the carrier's initial determination that the request is ineligible, and may require that the request be referred for an expedited independent review.

(ii) In making the determination in Subsection (2)(d)(i), the commissioner's decision shall be made in accordance with the terms of the insured's health benefit plan and shall be subject to this rule.

(3) Upon receiving the carrier's determination that a request is eligible for an expedited independent review, the commissioner shall immediately:

(a) assign an independent review organization from the list of approved independent review organizations;

(b) notify the carrier of the assignment and that the carrier shall, upon receipt, provide to the assigned independent review organization the documents and any information considered in making the adverse benefit determination; and

(c) notify the claimant that:

(i) the request is accepted; and

(ii) the claimant may immediately submit additional information to the independent review organization.

(4) The independent review organization shall forward any additional information submitted by a claimant under Subsection (3)(c)(ii) to the carrier within one business day of receipt.

(5)

(a) As expeditiously as the insured's medical condition or circumstance requires, but no later than 72 hours after receiving the request for an expedited independent review, the independent review organization shall provide notice of its decision to:

(i) the carrier;

(ii) the claimant; and

(iii) the commissioner.

(b) If notice of the independent review organization's decision is not in writing, the independent review organization shall provide written confirmation of its decision within 48 hours after the date of notification.

(6) Upon receiving notice that an adverse benefit determination is overturned, the carrier shall:

(a) approve the coverage that is the subject of the adverse benefit determination; and

(b) process any benefit that is due.

Notes

Utah Admin. Code R590-261-10

Amended by Utah State Bulletin Number 2023-10, effective 5/9/2023