58-17H-32. Notification of adverse determination--Contents.
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/sd/title-58/chapter-58-17/58-17h-32·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Any notification of an adverse determination under this section shall, in a manner which is designed to be understood by the covered person, set forth:
(1)Information sufficient to identify the benefit request or claim involved, including the date of service, if applicable, the health care provider, the claim amount, if applicable, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning;
(2)The specific reason or reasons for the adverse determination, including the denial code and its corresponding meaning, as well as a description of the health carrier's standard, if any, that was used in denying the benefit request or claim;
(3)A reference to the specific plan provision on which the determination is based;
(4)A description of additional material or information necessary for the covered person to complete the benefit request, including an explanation of why the material or information is necessary to complete the request;
(5)A description of the health carrier's grievance procedures established pursuant to chapter 58-17I , including time limits applicable to those procedures;
(6)If the health carrier relied upon an internal rule, guideline, protocol, or other similar criterion to make the adverse determination, either the specific rule, guideline, protocol, or other similar criterion or a statement that a specific rule, guideline, protocol, or other similar criterion was relied upon to make the adverse determination and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to the covered person upon request;
(7)If the adverse determination is based on a medical necessity or experimental or investigational treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the determination, applying the terms of the health benefit plan to the covered person's medical circumstances or a statement that an explanation will be provided to the covered person free of charge upon request;
(8)If applicable, instructions for requesting:
(a)A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the adverse determination, as provided in subdivision
(6)of this section; or
(b)The written statement of the scientific or clinical rationale for the adverse determination, as provided in subdivision
(7)of this section; and
(9)A statement explaining the availability of and the right of the covered person, as appropriate, to contact the Division of Insurance at any time for assistance or, upon completion of the health carrier's grievance procedure process as provided under chapter 58-17I , to file a civil suit in a court of competent jurisdiction.
If the adverse determination is a rescission, the health carrier shall provide, in addition to any applicable disclosures required under § 58-17H-32 , clear identification of the alleged fraudulent practice or omission or the intentional misrepresentation of material fact, an explanation as to why the act, practice, or omission was fraudulent or was an intentional misrepresentation of a material fact, and the effective date of the rescission.
A health carrier may provide the notice required under this section in writing or electronically.
If the adverse determination is a rescission, the health carrier shall provide advance notice of the rescission determination required by rules promulgated by the director, in addition to any applicable disclosures required under this section.
The health carrier shall provide clear identification of the alleged fraudulent act, practice, or omission or the intentional misrepresentation of material fact.
The health carrier shall provide an explanation as to why the act, practice, or omission was fraudulent or was an intentional misrepresentation of a material fact.
The health carrier shall provide notice that the covered person or the covered person's authorized representative, prior to the date the advance notice of the proposed rescission ends, may immediately file a grievance to request a review of the adverse determination to rescind coverage pursuant to chapter 58-17I .
The health carrier shall provide a description of the health carrier's grievance procedures established pursuant to chapter 58-17I , including any time limits applicable to those procedures.
The health carrier shall provide the date when the advance notice ends and the date back to which the coverage will be retroactively rescinded.