20-2533

20-2533. Denial; levels of review; disclosure;
additional time after service by mail; review process

A. Any member who is denied a covered service or whose claim for a service is
denied may pursue the applicable review process prescribed in this article. Except as
provided in sections 20-2534 and 20-2535, health care insurers shall provide at least the
following levels of review, as applicable:

1. An expedited medical review and expedited appeal pursuant to section 20-2534.

2. An informal reconsideration pursuant to section 20-2535.

3. A formal appeal process pursuant to section 20-2536.

4. An external independent review pursuant to section 20-2537.

B. A health care insurer may offer additional levels of review other than the
levels prescribed in subsection A of this section as long as the additional levels of
review do not increase the time period limitations prescribed by this article.

C. At the time coverage is initiated, each health care insurer that operates in
this state and whose utilization review system includes the power to affect the direct or
indirect denial of requested medical or health care services or claims for medical or
health care services shall include a separate information packet that is approved by the
director with the member's policy, evidence of coverage or similar document. At the time
coverage is renewed, each health care insurer shall include a separate statement with the
member's policy, evidence of coverage or similar document that informs the member that
the member can obtain a replacement packet that explains the appeal process by contacting
a specific department and telephone number. A health care insurer shall also provide a
copy of the information packet to the member or the member's treating provider on request
and to the member within five business days after the date the appeal is initiated
pursuant to section 20-2534, 20-2535 or 20-2536. The information packet provided by the
health care insurer shall include all of the following information:

1. A detailed description and explanation of each level of review prescribed in
subsection A of this section and notice of the member's right to proceed to the next
level of review if the prior review is unsuccessful.

2. An explanation of the procedures that the member must follow, including the
applicable time periods, for each level of review prescribed in subsection A of this
section and an explanation of how the member may obtain the member's medical records
pursuant to title 12, chapter 13, article 7.1.

3. The specific title and department of the person and the address, telephone
number and telefacsimile number of that person whom the member must notify at each level
of review prescribed in subsection A of this section in order to pursue that level of
review.

4. The specific title and department of the person and the address, telephone
number and telefacsimile number of the person who will be responsible for processing that
review.

5. A notice that if the member decides to pursue an appeal the member must provide
the person who will be responsible for processing the appeal with any material
justification or documentation for the appeal at the time that the member files the
written appeal.

6. A description of the utilization review agent's and health care insurer's roles
at each level of review prescribed by subsection A of this section and an outline of the
director's role during the external independent review process, if not already described
in response to paragraph 1 of this subsection.

7. A notice that if the member participates in the process of review pursuant to
this article the member waives any privilege of confidentiality of the member's medical
records regarding any person who examined or will examine the member's medical records in
connection with that review process for the medical condition under review.

8. A statement that the member is not responsible for the costs of any external
independent review.

9. Standardized forms that are prescribed by the department and that a member may
use to file and pursue an appeal.

10. The name and telephone number for the department of insurance consumer
assistance office with a statement that the department of insurance consumer assistance
office can assist consumers with questions about the health care appeals process.

D. At the time of issuing a denial, the health care insurer shall notify the member
of the right to appeal under this article. A health care insurer that issues an
explanation of benefits document shall satisfy this obligation by prominently displaying
in the document a statement about the right to appeal. A health care insurer that does
not issue an explanation of benefits document shall satisfy this obligation through some
other reasonable means to assure that the member is apprised of the right to appeal at
the time of a denial. A reasonable means that includes giving the member's treating
provider a form statement about the right to appeal shall require the treating provider
to notify the member of the member's right to appeal.

E. Any written notice, acknowledgment, request, decision or other written document
required to be mailed pursuant to this article is deemed received by the person to whom
the document is properly addressed on the fifth business day after the request is mailed.
For the purposes of this subsection "properly addressed" means the last known address.

F. The director shall require any member who files a complaint with the department
relating to an adverse decision to pursue the review process prescribed in this article.
This subsection does not limit the director's authority pursuant to chapter 1, article 2
of this title.

G. If the member's complaint is an issue of medical necessity under the coverage
document and not whether the claim or service is covered, the informal reconsideration
shall be performed as prescribed by section 20-2535 by a licensed health care
professional. If the member's complaint is an issue of medical necessity under the
coverage document and not whether the claim or service is covered, the expedited review
or formal appeal shall be decided by a physician, provider or other health care
professional as prescribed by section 20-2534 or 20-2536. Any external independent review
shall be decided by a physician, provider or other health care professional as prescribed
by section 20-2537.

H. Any person given access to a member's medical records or other medical
information in connection with proceedings pursuant to this article shall maintain the
confidentiality of the records or information in accordance with title 12, chapter 13,
article 7.1.