Sec. 21.07.005. Regulations relating to health care insurance policies.

187 words·~1 min read·/ak/title-21/chapter-7/21-07-005

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

(a)The director shall adopt regulations to provide standards and criteria for

(1)the structure and operation of utilization review and benefit determination processes;

(2)the establishment and maintenance of procedures by health care insurers to ensure that a covered individual has the opportunity for appropriate resolution of grievances; and

(3)an independent review of an adverse determination or final adverse determination.

(b)The regulations under

(a)of this section must be at least as restrictive as the Utilization Review and Benefit Determination Model Act adopted by the National Association of Insurance Commissioners on June 22, 2003, the Health Carrier Grievance Procedure Model Act adopted by the National Association of Insurance Commissioners on June 22, 2003, and the Uniform Health Carrier External Review Model Act adopted by the National Association of Insurance Commissioners on June 2, 2008.

(c)The director may adopt regulations for the registration and regulation of independent review organizations, including the establishment of fees in an amount the director determines to be sufficient to reimburse the state for actual expenses incurred in providing a service.