Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
031 - BUREAU OF INSURANCE
Chapter 850 - HEALTH PLAN ACCOUNTABILITY
Section 031-850-9 - Adverse Benefit Determinations not Involving Adverse Health Care Treatment Decisions
Universal Citation: 02 ME Code Rules ยง 031-850-9
Current through 2024-13, March 27, 2024
A . Notice of Adverse Benefit Determinations not Involving Health Care Treatment Decisions
Adverse benefit determinations involving medical issues (adverse health care treatment decisions) are subject to the written notice requirements of paragraph 8(E)(5). For any adverse benefit determination that does not involve medical issues, the carrier shall provide written notice that includes the information required below:
1) the principal reason or reasons for the
determination;
2) reference to the
specific plan provisions on which the determination is based;
3) information sufficient to identify the
claim involved (including the date of service, the health care provider, and
the claim amount if applicable), and a statement that the diagnosis code and
its corresponding meaning, and the treatment code and its corresponding
meaning, will be provided upon request;
4) a description of any additional material
or information necessary for the covered person to perfect the claim and an
explanation as to why such material or information is necessary;
5) the instructions and time limits for
initiating an appeal or reconsideration of the determination;
6) notice of the right to file a complaint
with the Bureau of Insurance after exhausting any appeals under a carrier's
internal review process. In addition, an explanation of benefits (EOB) must
comply with the requirements of
24-AM.R.S.A.
§4303(13) and any rules
adopted pursuant thereto.
7) if an
internal rule, guideline, protocol, or other similar criterion was relied upon
in making the adverse benefit determination, either the specific rule,
guideline, protocol, or other similar criterion; or a statement referring to
the rule, guideline, protocol, or other similar criterion that was relied upon
in making the adverse determination and explaining that a copy will be provided
free of charge to the covered person upon request;
8) a phone number the covered person may call
for information on and assistance with initiating an appeal or reconsideration
or requesting review criteria;
9) a
description of the expedited review process applicable to claims involving
exigent circumstances;
10) the
availability of any applicable office of health insurance consumer assistance
or ombudsman established under the federal Affordable Care Act; and 11) any
other information required pursuant to the federal Affordable Care
Act.
B. First Level Review of Adverse Benefit Determinations not Involving Health Care Treatment Decisions
1) A grievance concerning
any matter may be submitted by a covered person or a covered person's
representative. Appeals of adverse health care treatment decisions are subject
to the requirements of subsections
8(G) and
8 (G-1) of this rule. Review of other
grievances is subject to this subsection and subsection C of this
section.
2) A covered person does
not have the right to attend, or to have a representative in attendance, at the
first level grievance review, but is entitled to submit written material to the
reviewer. The health carrier shall provide the covered person the name, address
and telephone number of a person designated to coordinate the grievance review
on behalf of the health carrier. The health carrier shall make these rights
known to the covered person within 3 working days after receiving a grievance.
a) A health carrier shall issue a written
decision to the covered person within 30 days after receiving a grievance.
Additional time is permitted where the carrier can establish the 30-day time
frame cannot reasonably be met due to the carrier's inability to obtain
necessary information from a person or entity not affiliated with or under
contract with the carrier. The carrier shall provide written notice of the
delay to the covered person. The notice shall explain the reasons for the
delay. In such instances, decisions must be issued within 30 days after the
carrier's receipt of all necessary information. The person or persons reviewing
the grievance shall not be the same person or persons who made the initial
determination denying a claim or handling the matter that is the subject of the
grievance.
b) If the decision is
adverse to the covered person, the written decision shall contain:
i) The names, titles and qualifying
credentials of the person or persons participating in the first level grievance
review process (the reviewers).
ii) A statement of the reviewers'
understanding of the covered person's grievance and all pertinent facts.
iii) Reference to the specific plan
provisions on which the benefit determination is based.
iv) The reviewers' decision in clear terms,
including the specific reason or reasons for the adverse benefit determination.
v) A reference to the evidence or
documentation used as the basis for the decision. The decision shall include
instructions for requesting copies, free of charge, of all documents, records
and other information relevant to the claim, including any referenced evidence
or documentation not previously provided to the covered person.
vi) If an internal rule, guideline, protocol,
or other similar criterion was relied upon in making the adverse benefit
determination, either the specific rule, guideline, protocol, or other similar
criterion; or a statement referring to the rule, guideline, protocol, or other
similar criterion that was relied upon in making the adverse determination and
explaining that a copy will be provided free of charge to the covered person
upon request.
vii) A description of
the process to obtain a second level grievance review of a decision, the
procedures and time frames governing a second level grievance review, and the
rights specified in subparagraph C(3)(c). Notice to the enrollee describing any
subsequent external review rights, if required by
24-A M.R.S.A.
§4312(3).
viii) Notice of the availability of any
applicable office of health insurance consumer assistance or ombudsman
established under the federal Affordable Care Act.
ix) Notice of the covered person's right to
contact the Superintendent's office. The notice shall contain the toll free
telephone number, website address, and mailing address of the Bureau of
Insurance.
x) Any other
information required pursuant to the federal Affordable Care
Act.
C. Second Level Review of Adverse Benefit Determinations not Involving Health Care Treatment Decisions
1) A health carrier shall provide a second
level grievance review process to covered persons who are dissatisfied with a
first level grievance review determination under subsection B. The covered
person has the right to appear in person before authorized representatives of
the health carrier, and shall be provided adequate notice of that option by the
carrier.
2) The carrier shall
appoint a second level grievance review panel for each grievance subject to
review under this subsection. A majority of the panel shall consist of
employees or representatives of the health carrier who were not previously
involved in the grievance.
3)
Whenever a covered person has requested the opportunity to appear in person
before authorized representatives of the health carrier, a health carrier's
procedures for conducting a second level panel review shall include the
following:
a) The review panel shall schedule
and hold a review meeting within 45 days after receiving a request from a
covered person for a second level review. The review meeting shall be held
during regular business hours at a location reasonably accessible to the
covered person. The health carrier shall offer the covered person the
opportunity to communicate with the review panel, at the health carrier's
expense, by conference call, video conferencing, or other appropriate
technology. The covered person shall be notified in writing at least 15 days in
advance of the review date. The health carrier shall not unreasonably deny a
request for postponement of the review made by a covered person.
b) Upon the request of a covered person, a
health carrier shall provide to the covered person, free of charge, all
relevant information that is not confidential and privileged from disclosure to
the covered person.
c) A covered
person has the right to:
i) Attend the second
level review;
ii) Present his or
her case to the review panel;
iii)
Submit supporting material both before and at the review meeting;
iv) Ask questions of any representative of
the health carrier; and
v) Be
assisted or represented by a person of his or her choice.
d) If the health carrier will have an
attorney present to argue its case against the covered person, the carrier
shall so notify the covered person at least 15 days in advance of the review,
and shall advise the covered person of his or her right to obtain legal
representation.
e) The covered
person's right to a fair review shall not be made conditional on the covered
person's appearance at the review.
f) The review panel shall issue a written
decision to the covered person within 5 working days after completing the
review meeting. A decision adverse to the covered person shall include the
information specified in subparagraph B(2)(b).
Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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