58-17H-48. Notification of adverse determination--Requirements.
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If a health carrier's determination with respect to §§ 58-17H-40 to 58-17H-47 , inclusive, is an adverse determination, the health carrier shall provide notice of the adverse determination in accordance with this section. A notification of an adverse determination under this section shall, in a manner calculated 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 provisions on which the determination is based;
(4)A description of any additional material or information necessary for the covered person to complete the request, including an explanation of why the material or information is necessary to complete the request;
(5)A description of the health carrier's internal review procedures established pursuant to chapter 58-17I , including any time limits applicable to those procedures;
(6)A description of the health carrier's expedited review procedures established pursuant to §§ 58-17I-12 to 58-17I-16 , inclusive;
(7)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;
(8)If the adverse determination is based on a medical necessity or experimental or investigation 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;
(9)If applicable, instructions for requesting:
(a)A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the adverse determination in accordance with subdivision
(7)of this section; or
(b)The written statement of the scientific or clinical rationale for the adverse determination in accordance with subdivision
(8)of this section; and
(10)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.
A health carrier may provide the notice required under this section orally, in writing or electronically. If notice of the adverse determination is provided orally, the health carrier shall provide written or electronic notice of the adverse determination within three days following the oral notification.