State Codes and Statutes
Statutes > Utah > Title-31a > Chapter-22 > 31a-22-62931A-22-629. Adverse benefit determination review process.
(1) As used in this section:
(a) (i) "Adverse benefit determination" means the:
(A) denial of a benefit;
(B) reduction of a benefit;
(C) termination of a benefit; or
(D) failure to provide or make payment, in whole or in part, for a benefit.
(ii) "Adverse benefit determination" includes:
(A) denial, reduction, termination, or failure to provide or make payment that is based ona determination of an insured's or a beneficiary's eligibility to participate in a plan;
(B) with respect to individual or group health plans, and income replacement or disabilityincome policies, a denial, reduction, or termination of, or a failure to provide or make payment,in whole or in part, for, a benefit resulting from the application of a utilization review; and
(C) failure to cover an item or service for which benefits are otherwise provided becauseit is determined to be:
(I) experimental;
(II) investigational; or
(III) not medically necessary or appropriate.
(b) "Independent review" means a process that:
(i) is a voluntary option for the resolution of an adverse benefit determination;
(ii) is conducted at the discretion of the claimant;
(iii) is conducted by an independent review organization designated by the insurer;
(iv) renders an independent and impartial decision on an adverse benefit determinationsubmitted by an insured; and
(v) may not require the insured to pay a fee for requesting the independent review.
(c) "Independent review organization" means a person, subject to Subsection (6), whoconducts an independent external review of adverse determinations.
(d) "Insured" is as defined in Section 31A-1-301 and includes a person who is authorizedto act on the insured's behalf.
(e) "Insurer" is as defined in Section 31A-1-301 and includes:
(i) a health maintenance organization; and
(ii) a third party administrator that offers, sells, manages, or administers a healthinsurance policy or health maintenance organization contract that is subject to this title.
(f) "Internal review" means the process an insurer uses to review an insured's adversebenefit determination before the adverse benefit determination is submitted for independentreview.
(2) This section applies generally to health insurance policies, health maintenanceorganization contracts, and income replacement or disability income policies.
(3) (a) An insured may submit an adverse benefit determination to the insurer.
(b) The insurer shall conduct an internal review of the insured's adverse benefitdetermination.
(c) An insured who disagrees with the results of an internal review may submit theadverse benefit determination for an independent review if the adverse benefit determinationinvolves:
(i) payment of a claim regarding medical necessity; or
(ii) denial of a claim regarding medical necessity.
(4) The commissioner shall adopt rules that establish minimum standards for:
(a) internal reviews;
(b) independent reviews to ensure independence and impartiality;
(c) the types of adverse benefit determinations that may be submitted to an independentreview; and
(d) the timing of the review process, including an expedited review when medicallynecessary.
(5) Nothing in this section may be construed as:
(a) expanding, extending, or modifying the terms of a policy or contract with respect tobenefits or coverage;
(b) permitting an insurer to charge an insured for the internal review of an adversebenefit determination;
(c) restricting the use of arbitration in connection with or subsequent to an independentreview; or
(d) altering the legal rights of any party to seek court or other redress in connection with:
(i) an adverse decision resulting from an independent review, except that if the insurer isthe party seeking legal redress, the insurer shall pay for the reasonable attorney fees of theinsured related to the action and court costs; or
(ii) an adverse benefit determination or other claim that is not eligible for submission toindependent review.
(6) (a) An independent review organization in relation to the insurer may not be:
(i) the insurer;
(ii) the health plan;
(iii) the health plan's fiduciary;
(iv) the employer; or
(v) an employee or agent of any one listed in Subsections (6)(a)(i) through (iv).
(b) An independent review organization may not have a material professional, familial,or financial conflict of interest with:
(i) the health plan;
(ii) an officer, director, or management employee of the health plan;
(iii) the enrollee;
(iv) the enrollee's health care provider;
(v) the health care provider's medical group or independent practice association;
(vi) a health care facility where service would be provided; or
(vii) the developer or manufacturer of the service that would be provided.
Amended by Chapter 307, 2007 General Session
