Utah Admin. Code R590-285-24 - Appealing an Insurer's Determination That the Benefit Trigger is Not Met

(1) If an insurer determines that a benefit trigger is not met, it shall provide a clear, written notice to the insured and the insured's authorized representative, if applicable, of the following:

(a) the reason the insurer determined the insured's benefit trigger is not met;

(b) the insured's right to an internal appeal, including the right to submit new or additional information relating to the benefit trigger denial; and

(c) the insured's right, after exhaustion of the insurer's internal appeal process, to have the benefit trigger determination reviewed under an independent review process.

(2)

(a) An insured or an insured's authorized representative may appeal the insurer's adverse benefit trigger determination by sending a written request to the insurer, along with any additional supporting information, within 180 days after the insured and the insured's authorized representative, if applicable, receives the adverse benefit trigger determination notice.

(b) An internal appeal shall be considered by an individual or group of individuals designated by the insurer, provided that the individual or individuals making the internal appeal decision may not be the same individual or group of individuals who made the initial adverse benefit trigger determination.

(c) An internal appeal shall be completed and written notice of the internal appeal decision shall be sent to the insured and the insured's authorized representative, if applicable, within 30 calendar days of the insurer's receipt of all information necessary to make a final determination.

(d) If an insurer's original determination is upheld after an internal appeal process has been exhausted, and new or additional information was not provided to the insurer, the insurer shall provide a written description of the insured's right to request an independent review of the adverse benefit trigger determination under Section R590-285-25 to the insured and the insured's authorized representative, if applicable.

(e) The written description of the insured's right to request an independent review shall include the following, or substantially equivalent, language: "We have determined that the benefit eligibility criteria ("benefit trigger") of your (insert either policy or certificate) has not been met. You may have the right to an independent review of our decision conducted by long-term care professionals who are not associated with us. Please send a written request for independent review to us at (insert address). You must inform us, in writing, of your election to have this decision reviewed within 180 days of receipt of this letter. We will choose an independent review organization for you and refer the request for independent review."

(f) If an insurer does not believe the adverse benefit trigger decision is eligible for an independent review, the insurer shall inform the insured and the insured's authorized representative, if applicable, in writing and include the reasons for its determination of independent review ineligibility.

(g) The appeal process is not a new service or provider under Section R590-285-20 and does not trigger the notice requirements of that section.

Notes

Utah Admin. Code R590-285-24

Adopted by Utah State Bulletin Number 2021-05, effective 2/23/2021 Adopted by Utah State Bulletin Number 2024-21, effective 10/22/2024