Current through Register Vol. 49, No. 9, September, 2024
§ 1.
Purpose
The purpose of this rule is to define certain minimum standards
which, if violated with such frequency as to indicate a general business
practice, will be deemed to constitute unfair claims settlement practices. Ark.
Code Ann. §§
23-66-201 (1987), et seq., and
23-76-103
(1987),
23-76-119
(1987) and
23-94-204
(Supp. 1987) prohibit insurers, health maintenance organizations and risk
retention groups doing business in the State of Arkansas from engaging in
unfair claims settlement practices; and provide that, if any insurer or health
maintenance organization or risk retention group performs any of the acts or
practices proscribed by those sections with such frequency as to indicate a
general business practice, then those acts shall constitute an unfair or
deceptive act or practice in the business of insurance.
§ 2.
Authority
This rule is issued pursuant to the authority vested in the
Commissioner by Ark. Code Ann. §§
23-61-108
(1987),
23-66-207
(1987),
23-76-125 (1987),
23-94-107 (Supp. 1987),
25-15-202
(1987), et seq., and other applicable provisions of Arkansas law.
§ 3.
Applicability and
scope
This rule applies to all persons, to all insurance policies and
insurance contracts and to all contracts, certificates, subscriber agreements,
or other evidences of coverage issued by insurers, health maintenance
organizations and risk retention groups, as applicable, except policies of
Workers' Compensation and Employer's Liability. This rule is not exclusive, and
other acts, not herein specified, may also be deemed to be a violation of Ark.
Code Ann. §§
23-66-201 (1987), et seq., and
23-76-103
(1987), and
23-76-119
(1987).
§ 4.
Effective date
The amendments adopted to this Rule and Regulation under Section
9(a)(2) and 9(d), related to the advance written notice to claimants of statute
of limitations or time period limitations, shall only apply on and after
December 1, 2015. All other provisions of Rule and Regulation 43, not amended
in 2015, which existed prior to December 1, 2015, shall remain in
effect.
§ 5.
Definitions
The definitions of "person," "evidence of coverage," and of
"insurance policy or insurance contract" contained in the Trade Practices Act,
Ark. Code Ann. §
23-66-203
(1987), and in Ark. Code Ann. §
23-76-102
(1987), shall apply to this regulation and, in addition, where used in this
regulation:
(a) "Agent" or
"Representative" means any individual, corporation, association, partnership or
other legal entity authorized to represent an insurer, health maintenance
organization, or risk retention group with respect to a claim;
(b) "Automobile insurance" includes, but is
not limited to, insurance as defined under Ark. Code Ann.
23-89-301
(1987);
(c) "Claimant" means an
enrollee, a first party claimant, and/or a third party claimant, and includes
such claimant's designated legal representative and includes a member of the
claimant's immediate family designated by the claimant;
(d) "Complaint" means a written communication
primarily expressing a grievance;
(e) "First party claimant" means an
individual, corporation, association, partnership or other legal entity
asserting a right to payment or services under an insurance policy or contract,
or health care plan arising out of the occurrence of the contingency, loss,
injury, or illness covered by such policy, or contract, or plan;
(f) "Insurance Department Complaint" means a
written communication regarding a complaint transmitted by the Arkansas
Insurance Department;
(g) "Insurer"
means any person, or risk retention group licensed or registered to issue or
who issues any insurance policy or contract in this State;
(h) "Investigation" means all activities of
an insurer directly or indirectly related to determination of liabilities or
obligations under coverages afforded by a policy, contract, or health care
plan;
(i) "Notification of claim"
means any notification, whether in writing or by other means acceptable under
the terms of an insurance policy, contract, or health care plan to an insurer
or its agent by a claimant, which reasonably apprises the insurer of the facts
pertinent to a claim;
(j) "Risk
retention group" means a group as defined under Ark. Code Ann. §
23-94-102(10) (Supp. 1987);
(k)
"Third party claimant" means any individual, corporation, association,
partnership or other legal entity asserting a claim against any individual,
corporation, association, partnership or other legal entity insured under an
insurance policy or insurance contract; and
(l) "Workers' Compensation" includes, but is
not limited to, Longshoremen's and Harbor Workers' Compensation.
(m) "Health Carrier" means a health
maintenance organization, hospital medical service corporation or a disability
insurance company, that issues Health Insurance Contracts as defined in
Subsection 5(s) of this rule. For purposes of this rule, unless otherwise
stated, the term "Health Carrier" shall include a self-insured governmental or
church plan, as well as third party administrators that administer or adjust
disability benefits for a disability insurer, hospital medical service
corporation, health maintenance organization, self-insured governmental plan or
self-insured church plan. A Health Carrier does not include an automobile
insurer paying medical or hospital benefits under Ark. Code Ann. §
23-89-202(1)
nor shall it include a self-insured employer health benefits plan. A Health
Carrier also does not include any person, company, or organization, licensed or
registered to issue or who issues any insurance policy or insurance contract in
this State as described in Ark. Code Ann. §§
23-62-102,
23-62-104,
23-62-105,
23-62-106, and
23-62-107
providing medical or hospital benefits for accidental injury or
disability.
(n) "Health Claimant"
means a Health Insured, a provider holding a valid assignment from the Health
Insured, or a provider contracted with a Health Carrier, who is claiming a
benefit under a Health Insurance Contract.
(o) "Health Claim Processing" or "to process
a health claim" means to pay the claim, to deny the claim or to notify the
Health Claimant in accordance with Subsection 12(b) and Subsection 13(a) of
this rule that the Health Carrier needs additional information to process the
Health Claim.
(p) "Health Claim
Processing Date" or "Health Claim Payment Date" is the date the Health Carrier
transmits or mails its claim payment, claim denial or notice of the need for
additional information to the Health Claimant.
(q) "Clean Claim" means a claim for payment
of health care expenses that is Submitted on a HCFA 1500, on a UB92, in a
format required by the Health Insurance Portability and Accountability Act of
1996 ("HIPAA"), or on the carrier's standard claim form with all required
fields completed in accordance with the Health Carrier's published claim filing
requirements. A Clean Claim shall not include a claim (1) for payment of
expenses incurred during a period of time for which premiums are delinquent,
(2) for benefits under a Medicare supplement policy if the claim is not
accompanied by an explanation of Medicare benefits or the Explanation of
Medicare Benefits ("EOMB") has not been otherwise received by the Health
Carrier, or (3) for which the Health Carrier needs additional information in
order to resolve one or more of the issues listed in Subsection 13(b) of this
rule.
(r) "Contracted Provider"
means a provider that contracts with a Health Carrier to provide services for
"Health Insureds" of such carrier.
(s) "Health Insurance Contract" means a
disability insurance policy, a hospital medical service corporation contract, a
health maintenance organization contract or a plan document issued or provided
by a Health Carrier as defined in Subsection 5(m) of this rule. Health
Insurance Contract shall not include a disability income insurance policy, a
long-term care contract, a hospital indemnity contract, an accident only
contract, or any other form of disability insurance policy that provides a
benefit as a result of a sickness or accident that does not directly cover
expenses related to health care treatment the insured receives.
(t) "Health Insured" means an individual who
is a covered person under a "Health Insurance Contract."
(u) "Health Policyholder" means the person
who owns the "Health Insurance Contract" and is responsible to pay premiums for
the "Health Insurance Contract."
(v) "Provider" means a physician, hospital or
other appropriately licensed health care provider.
§ 6.
File and record
documentation
The claim files of insurers, including Health Carriers, shall be
subject to examination by the Commissioner or by his duly appointed designees.
Such files shall contain all notes and work papers pertaining to the claim in
such detail that pertinent events and the dates of such events can be
reconstructed.
§ 7.
Failure to acknowledge pertinent communications
The provisions of this section shall not apply to persons that
are defined as Health Carriers under Section 5(m) of this Rule.
(a) Every insurer, upon receiving
notification of a claim shall, within fifteen (15) working days, acknowledge
the receipt of such notice unless payment is made within such period of time.
If an acknowledgement is made by means other than in writing, an appropriate
notation of such acknowledgement shall be made in the claim file of the insurer
and dated. Notification given to an agent of an insurer shall be notification
to the insurer. Pursuant to Ark. Code Ann. §
23-79-126
(1987), insurers shall furnish forms for proof of loss within twenty (20)
calendar days after a loss has been reported, or thereafter waive proof of loss
requirements. Insurers shall not require a claimant to calculate depreciated
value of personal property on forms for proof of loss.
(b) Every insurer upon receipt of any inquiry
from the Arkansas Insurance Department respecting a claim shall within fifteen
(15) working days of such inquiry furnish the Department with a reasonably
adequate response to the inquiry.
(c) An appropriate reply shall be made within
fifteen (15) working days on all other pertinent communications from a claimant
which reasonably suggest that a response is expected.
(d) Every insurer, upon receiving
notification of a claim, shall promptly provide necessary claim forms,
instructions, and reasonable assistance to claimants so that first party
claimants can comply with the policy conditions and the insurer's reasonable
requirements.
§ 8.
Standards for prompt investigation of claims
The provisions of this section shall not apply to persons that
are defined as Health Carriers under Section 5(m) of this Rule.
Every insurer shall complete investigation of a claim within
forty-five (45) calendar days after notification of claim, unless such
investigation cannot reasonably be completed within such time. If an
investigation cannot be completed within the forty-five (45) day time period,
insurers shall notify claimants that additional time is required and include
with such notification the reasons therefore.
§ 9.
Standards for prompt, fair
and equitable settlements applicable to insurers
The provisions of this section shall not apply to persons that
are defined as Health Carriers under Section 5(m) of this Rule, nor to surety
and fidelity insurance, or to mortgage guaranty, or other forms of insurance
offering protection against investment risks.
(a)
(1)
Within fifteen (15) working days after receipt by the insurer of properly
executed proofs of loss, the first party claimant shall be advised of the
acceptance or denial of the claim by the insurer. No insurer shall deny a claim
on the grounds of a specific policy provision, condition, or exclusion unless
reference to such provision, condition, or exclusion is included in the denial.
The denial must be given to the claimant in writing and the claim file of the
insurer shall contain a copy of the denial.
(2) If the insurer needs more time to
determine whether a first party claim should be accepted or denied, it shall so
notify the first party claimant in writing within fifteen (15) working days
after receipt of the proofs of loss, stating the reasons more time is needed.
If the investigation remains incomplete, the insurer shall, within forty-five
(45) calendar days from the date of the initial notification and not more than
every forty-five (45) calendar days thereafter, send to such claimant a letter
setting forth the reasons additional time is needed for
investigation.
(b) Where
there is a reasonable basis supported by specific information available for
review by the Arkansas Insurance Department that the first party claimant has
fraudulently caused or contributed to the loss by arson, the insurer is
relieved from the requirements of subsection (a)(1). The claimant shall be
advised of the acceptance or denial of the claim within a reasonable time
following a full investigation after receipt by the insurer of a properly
executed proof of loss. The insurer shall comply with the provisions of the
Arson Reporting-Immunity Statute, Ark. Code Ann. §§
12-13-301
(1987)-
12-13-305
(1987).
(c) Insurers shall not
refuse to settle first party claims on the basis that responsibility for
payment should be assumed by others, except as may otherwise be provided by
policy provisions.
(d) Insurers
shall not continue or prolong negotiations for settlement of a claim directly
with a claimant who is neither an attorney nor represented by an attorney until
the claimant's rights may be affected by a statute of limitations or a policy
or contract time limit, without giving the claimant written notice that the
time limit may be expiring and may affect the claimant's rights. Such notice
shall be given to first party claimants at least thirty (30) working days and
to third party claimants at least sixty (60) calendar days before the date on
which such time limit may expire.
(e) No insurer shall make statements which
indicate the rights of a third party claimant may be impaired if a form or
release is not completed within a given period of time unless the statement is
given for the purpose of notifying the third party claimant of the applicable
provision of a statute of limitations, as provided in subsection (d) of this
section.
(f) Insurers shall mail or
deliver claim checks or drafts to claimants within ten (10) working days after
the claims are processed, all claim investigations are completed and said claim
files are closed and ready for payment.
(g) No insurer or its agents and
representatives shall fail to disclose fully to first party claimants all
pertinent benefits, coverages or other provisions of an insurance policy or
contract under which a claim is presented.
(h) No agent shall conceal from first party
claimants benefits, coverages or other provisions of any insurance policy or
insurance contract when such benefits, coverages or other provisions are
pertinent to a claim.
(i) No
insurer shall deny a claim for a claimant's failure to exhibit the damaged
property without proof of demand and of an unfounded refusal by the claimant to
do so.
(j) No insurer shall, except
where there is a time limit specified in the policy, make statements, written
or otherwise, requiring a claimant to give written notice of loss or proof of
loss within a specified time and which seek to relieve the company of its
obligations if such a time limit is not complied with, unless the failure to
comply with such time limit prejudices the insurer's rights.
(k) No insurer shall request a first party
claimant to sign a release that extends beyond the subject matter that gave
rise to the claim payment.
(l) No
insurer shall issue checks or drafts in partial settlement of a loss or claim
under a specific coverage which contains language which releases the insurer or
its insured from total liability.
(m) No insurer shall delay payment of any
claim under specific coverages under a contract in an attempt to settle all or
a portion of the claims under other coverages provided by the policy.
§ 10.
Standards for
prompt, fair and equitable settlements applicable to private passenger
automobile insurance
The provisions of this section shall not apply to persons that
are defined as Health Carriers under Section 5(m) of this Rule.
(a) When the insurance policy provides for
the adjustment and settlement of first party automobile total losses on the
basis of actual cash value or replacement with another of like kind and
quality, one (1) of the following methods must apply:
(1) The insurer may elect to offer a
replacement automobile which is a specific comparable automobile available to
the insured. All applicable taxes, license fees and other fees incident to
transfer of evidence of ownership of the automobile must be paid at no cost to
the insured other than the policy deductible. The offer and any rejection
thereof must be documented in the claim file.
(2) The insurer may elect a cash settlement
based upon the actual cost, less any deductible provided in the policy, to
purchase a comparable automobile, including all applicable taxes, license fees
and other fees actually incurred incident to transfer of evidence of ownership
of a comparable automobile. Such cost may be determined by:
(A) The cost of a comparable automobile in
the local market area when a comparable automobile is available in the local
market area; or
(B) Use of one (1)
of two (2) or more quotations obtained by the insurer from two (2) or more
qualified dealers or appraisal services located within the local market area
when a comparable automobile is not available in the local market
area.
(3) When a first
party automobile total loss is settled on a basis which deviates from the
methods described in subsections (a)(1) and (2) of this section, the deviation
must be supported by documentation giving particulars of the automobile's
condition. Any deductions from such cost, including deduction for salvage, must
be measurable, discernible, itemized and specified as to dollar amount and
shall be appropriate in amount. The basis for such settlement shall be fully
explained to the first party claimant.
(b) Where liability and damages are
reasonably clear, insurers shall not recommend or require that third party
claimants make a claim under their own policies solely to avoid paying claims
under such insurer's policy or contract.
(c) Insurers shall not require a claimant to
travel an unreasonable distance to inspect a replacement automobile, to obtain
a repair estimate, or to have the automobile repaired at a specific repair
shop. Insurers shall not require a claimant to have the automobile repaired at
a specific repair shop as a condition of recovery.
(d) Insurers shall include the first party
claimant's deductible, if any, in subrogation demands. Subrogation recoveries
shall be shared on a proportionate basis with the first party claimant, unless
the deductible amount has been otherwise recovered. No deduction for expenses
can be made from the deductible recovery unless an outside attorney is retained
to collect such recovery. The deduction may then be for only a pro rata share
of the allocated loss adjustment expense.
(e) When the insurer elects to repair, and,
with the insured's written consent, a specific repair shop is selected, the
insurer shall cause the damaged automobile to be restored to its condition
prior to the loss at the estimate cost with no additional cost to the claimant
other than as stated in the policy and within a reasonable period of
time.
(f) If an insurer prepares an
estimate of the cost of automobile repairs, such estimate shall be in an amount
for which it may be reasonably expected the damage can be satisfactorily
repaired. The insurer shall give a copy of the estimate to the claimant and may
furnish to the claimant the names of one (1) or more conveniently located
repair shops.
(g) When the amount
claimed is reduced because of betterment or depreciation all information for
such reduction shall be contained in the claim file. Such deductions shall be
itemized and specified as to dollar amount and shall be appropriate for the
amount of deductions.
§
11.
Claim Filing Requirements of "Health Carriers"
The provisions of this section shall only apply to person that
are defined as Health Carriers under Section 5(m) of this Rule.
(a) Every Health Carrier upon receipt of any
written inquiry from the Arkansas Insurance Department respecting a claim shall
within fifteen (15) working days of such inquiry furnish the Department with a
reasonably adequate response to the inquiry.
(b) If, after receipt of a complaint, the
Commissioner determines that a Health Carrier's claim filing requirements are
unreasonable or unduly burdensome, the Commissioner shall direct the Health
Carrier to discontinue using such claim filing requirements.
(c) A Health Carrier shall provide a copy of
its claim filing requirements to:
(1) a
contracted provider at the time the Health Carrier and provider enter into
their contract and within 15 days prior to a change to the claim filing
requirements.
(2) a Health Care
Insured or provider upon request, within 15 days;
§ 12.
Processing of Clean Claims
The provisions of this section shall only apply to persons that
are defined as Health Carriers under Section 5(m) of this Rule.
(a) A Health Carrier shall pay or deny a
clean claim within 30 days after receipt by the Health Carrier if the claim was
submitted electronically, or within 45 days after receipt if the claim was
submitted by other means.
(b) A
Health Carrier shall notify the Health Claimant within 30 days after receipt of
the claim if the Health Carrier determines that the claim must be processed in
accordance with Section 13 of this rule.
(c) A Health Carrier which fails to pay or
deny a clean claim in accordance with Subsection (a) of this section or give
notice in accordance with Subsection (b) of this section shall pay a penalty to
the Health Claimant for the period beginning on the sixty-first day after
receipt of the clean claim and ending on the clean claim payment date (the
delinquent payment period), calculated as follows: the amount of the clean
claim payment times 12% per annum times the number of days in the delinquent
payment period, divided by 365. Such penalty shall be paid without any action
by the Health Claimant.
§
13.
Processing of Claims Requiring Additional
Information
The provisions of this section shall only apply to persons that
are defined as Health Carriers under Section 5(m) of this Rule.
(a) If the resolution of the claim requires
the Health Carrier to obtain additional information to resolve one or more of
the issues listed in subsection (b) of this section, the Health Carrier shall,
within 30 days after receipt of the claim, notify the Health Claimant. The
Health Carrier's notice shall give an explanation of the additional information
that is required. The Health Carrier may suspend the claim until it receives
the requested information, or in the case of a Medicare supplement policy, the
claim may be suspended until the Health Carrier receives the EOMB.
(b) When there is a reasonable basis for
doing so, a Health Carrier may request one or more of the following items to
resolve the claim:
1. information in order to
determine if a Health Insurance Contract limitation or exclusion is applicable
to the claim;
2. medical
information in order to determine the price for a medical procedure without a
Current Procedural Terminology (CPT) Code or a Health Care Financing
Administration Common Procedure (HCPC) Code;
3. information in order to determine if a
Health Insured who received the claimed services is eligible under the terms of
the Health Insurance Contract;
4.
information in order to determine if the claim is covered by another Health
Carrier, workers' compensation, a government supported program, or a liable
third party;
5. information in
order to determine the obligation of each Health Carrier or government program
under coordination of benefits rules;
6. information in order to determine if there
has been fraud or a fraudulent or material misrepresentation with respect to
the claim; or
7. payment from the
policyholder of premiums that were delinquent at the time the claimed services
were rendered.
(c) A
Health Carrier shall reopen and pay or deny a previously suspended claim within
30 days after the Health Carrier receives all the information it
requested.
(d) A Health Carrier
which fails to pay or deny a claim in accordance with Subsection C of this
section, and that is not already subject to the penalty for the claim imposed
by Subsection 12(c), shall pay a penalty to the Health Claimant for the period
beginning on the forty-sixth day after the last item of information requested
was received and ending on the claim payment date (the delinquent payment
period), calculated as follows: the amount of the claim payment times 12% per
annum times the number of days in the delinquent payment period, divided by
365. Such penalty shall be paid without any further action by the Health
Claimant.
§ 14.
Claim Processing Standards For Health Carriers
The provisions of this section shall only apply to persons that
are defined as Health Carriers under Section 5.(m) of this Rule.
(a) Every Health Carrier doing business in
this state shall strive to meet the following claim timeliness standards for
processing clean claims and other [Section 13] claims:
Eighty-five (85%) percent of claims processed within 30 days
Ninety-eight (98%) percent of claims processed within 45 days
(b) If requested by the Commissioner, a
Health Carrier shall provide a claims processing report showing the percentage
of clean claims and other claims the carrier processed for residents of this
state during the previous quarter and year to date. The report will classify
claims as follows:
Clean Claims
Percent of claims processed within 30 days following receipt of
the claim
Percent of claims processed within 45 days following receipt of
the claim
Percent of claims processed after 45 days following receipt of
the claim
Other [Section 13] Claims
(1) Percent of claims processed within 30
days following reopening of the claim.
(2) Percent of claims processed within 45
days following reopening of the claims.
(3) Percent of claims processed after 45 days
following receipt of the claim.
(c) If a claims processing report to the
Commissioner or other evidence obtained by the Commissioner shows a Health
Carrier's clean claim or other [Section 13] Health Claim Processing has fallen
below the following regulatory action standards:
Sixty (60%) percent of claims processed within 30 days
Eighty-five (85%) percent of claims processed within 45 days
1. the Health Carrier shall be required to
submit to the Commissioner a remedial action plan setting forth how and when
its Health Claim Processing shall be brought above the regulatory action
standards. In addition, at the Commissioner's option, the Commissioner may
conduct an on site examination of the Health Carrier's Health Claim
Processing.
2. Depending upon the
Health Carrier's response, the Commissioner, at his option, may require the
Health Carrier to provide notice to its Health Claimants and contracted
providers of delays in Health Claim Processing and the steps being taken to
improve this status.
3. A Health
Carrier which has failed to meet the regulatory action standards shall be
required to provide the Commissioner a claim processing report on a monthly
basis until the Health Carrier meets the 85% and 98% standards for both clean
claim and other [Section 13] claim processing for two consecutive
quarters.
4. Nothing in this rule
shall limit or restrict the Commissioner from pursuing any other remedy or
action against the Health Carrier under Ark. Code Ann. §
23-66-201 (1987), nor act to limit
any other administrative action against a Health Carrier under the Arkansas
Insurance Code.
(d) A
Health Carrier may be waived from the Health Claim Processing standards under
this Section 9 if its Health Claim Processing system is seriously impacted by a
natural disaster or if the Health Carrier obtains approval from the
Commissioner for a good cause shown. A Health Carrier, in requesting the
Commissioner's waiver of the Health Claim Processing standards, must specify
the reason(s), give its best estimate when the Health Claim Processing
standards will again be met, and commit to provide the Commissioner periodic
progress reports. In the case of a natural disaster, the Health Carrier shall
notify the Commissioner as soon as possible after the event, specify when the
claims system will be restored and commit to submitting periodic progress
reports to the Commissioner. The Commissioner shall publish a waiver granted to
a Health Carrier on the Arkansas Insurance Department web
site.
§ 15.
Request for Investigation
The provisions of this section shall only apply to persons that
are defined as Health Carriers under Section 5.(m) of this Rule.
(a) A Health Claimant may file a consumer
complaint with the Commissioner relating to a Health Carrier when there is a
reasonable basis for such complaint due to the failure of the Health Carrier to
process claims according to this rule. However, if the Health Claimant is not
the actual insured under the policy, nor the enrollee in the plan, the Health
Claimant may file a consumer complaint with the Commissioner where there is a
reasonable basis to believe that the Health Carrier has exhibited a practice of
not paying that provider's claims according to this rule.
(b) The Commissioner shall investigate such
complaint and shall make a report of his findings available to the Health
Claimant who filed the complaint.
§ 16.
Minimum standards for
pre-certification or pre-authorization reviews as to disability coverage
The purpose of this section is to define certain minimum
standards for insurers utilizing pre-certification or pre-authorization reviews
to ensure that such cost-containment procedures of disability insurers and
health care plans are reasonable and do not unduly delay, or interfere with or
impede the authorized practice of medicine and delivery of reasonable medical
care. For purposes of this rule, acts of the claims administrator in performing
pre-certification reviews shall be deemed to be acts of the insurer.
From and after one hundred and eighty (180) days from the
effective date of this rule, insurers utilizing such reviews shall establish
reasonable procedures to:
(a) Ensure
that pre-certification reviews are completed in a prompt and timely
manner;
(b) Avoid excessive,
repetitious and duplicative requests for information to claimants and their
health care providers;
(c) Provide
for reconsideration or medical reviews following disapproval or denial of
pre-certification requests of insureds and claimants; and
(d) Provide for prompt peer medical review
following disapproval or denial of pre-certification requests of insureds or
claimants as to medically-necessary and/or life-threatening major surgical
procedures.
§ 17.
Severability
Any section or provision of this rule held by a court to be
invalid or unconstitutional will not affect the validity of any other section
or provision of this rule.
