Utah Administrative Code
Topic - Insurance
Title R590 - Administration
Rule R590-261 - Health Benefit Plan Adverse Benefit Determinations
Section R590-261-9 - Standard Independent Review
Universal Citation: UT Admin Code R 590-261-9
Current through Bulletin 2024-06, March 15, 2024
(1)
(a) Upon receiving a request for an
independent 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, the carrier shall determine if:
(i) the individual was an insured in the
health benefit plan at the time:
(A) of
rescission; or
(B) the health care
service was requested or provided; (ii) the health care service is a covered
benefit;
(iii) the
claimant exhausted the carrier's internal review process; and
(iv) the claimant provided the information
and forms required to process an independent review.
(c)
(i)
Within one business day after completing the eligibility review, the carrier
shall notify the commissioner and 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 the
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 may require that the
request be referred for independent review.
(ii) In making the determination in
Subsection (1)(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 all
applicable provisions of this rule.
(2) Upon receiving a carrier's determination that a request is eligible for an independent review, the commissioner shall:
(a) assign, on a random basis, an independent
review organization from the list of approved independent review organizations
based on the nature of the health care service that is the subject of the
review;
(b) notify the carrier of
the assignment and that the carrier shall, within five business days, 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 for independent review is
accepted; and
(ii) the claimant may
submit additional information to the independent review organization within
five business days of receiving the commissioner's notification.
(3) The independent review organization shall forward any additional information submitted by a claimant under Subsection (2)(c) to the carrier within one business day of receipt.
(4) Within 45 calendar days after receiving a request for an independent review, the independent review organization shall provide written notice of its decision to:
(a) the claimant;
(b) the carrier; and
(c) the commissioner.
(5) 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.
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