Utah Admin. Code R590-261-11 - Independent Review of Experimental or Investigational Service or Treatment

(1)

(a) A request for an independent review, based on an experimental or investigational service or treatment, shall be submitted with certification from the insured's health care provider that:

(i) the standard health care service or treatment is not effective in improving the insured's condition;

(ii) the standard health care service or treatment is not medically appropriate for the insured; or

(iii) there is no available standard health care service or treatment covered by the carrier that is more beneficial than the recommended or requested health care service or treatment.

(b) A claimant may make an oral or written request for an expedited independent review if the insured's health care professional certifies, in writing, that the recommended or requested health care service or treatment would be significantly less effective if not initiated promptly.

(2)

(a) Within one business day after receiving a request for an independent review involving an experimental or investigational service or treatment, or immediately for an expedited review, the commissioner shall send a copy of the request to the carrier for an eligibility review.

(b) Within five business days after receiving the request, or immediately for an expedited review, 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 or treatment is a covered benefit, except for the carrier's determination that the service or treatment:

(A) is experimental or investigational for a particular medical condition; and

(B) is not explicitly listed as an excluded benefit under the insured's health benefit plan;

(iii) the insured's health care provider:

(A) has certified one of the following situations applies:

(I) the standard health care services have not been effective in improving the condition of the insured;

(II) the standard health care services or treatments are not medically appropriate for the covered person; or

(III) there is no available standard health care service or treatment covered by the carrier that is more beneficial than the recommended or requested health care service or treatment;

(B) has certified in writing:

(I) in their opinion, the health care service or treatment is likely to be more beneficial to the insured than any available standard health care service or treatment; and

(II) scientifically valid studies using accepted protocols demonstrate that the health care service or treatment is likely to be more beneficial to the insured than any available standard health care service or treatment; and

(C) is licensed, board certified, or board eligible to practice in the area of medicine appropriate to treat the insured's condition;

(iv) the claimant exhausted the carrier's internal review process, unless the request is for an expedited review; and

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

(c)

(i) Within one business day after completing the eligibility review, or immediately for an expedited review, the carrier shall notify the commissioner and the claimant, in writing, if:

(A) the request is complete; and

(B) the request is eligible for independent review.

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

(iii) If the request is not eligible for 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 independent review, notwithstanding the carrier's initial determination that the request is ineligible, and require that the request be referred for 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 health benefit plan and shall be subject to all applicable provisions of this rule.

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

(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, within five business days, or immediately for an expedited review, 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 the request has been accepted and that the claimant may, within five business days, or immediately for an expedited review, 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) to the carrier within one business day of receipt, or immediately for an expedited review.

(5) Within one business day after receiving the request, or immediately for an expedited review, the independent review organization shall select one or more clinical reviewers to conduct the review.

(6) The clinical reviewer shall provide to the independent review organization a written opinion within 20 calendar days, or five calendar days for an expedited review, after being selected.

(7) The independent review organization, within 20 calendar days of receiving the clinical reviewer's opinion, or no later than 72 hours for an expedited review, shall provide notice of its decision to:

(a) the claimant;

(b) the carrier; and

(c) the commissioner.

(8) Within one business day of 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 R590-261-11

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