58-17H-28 Prospective review determinations--Timing--Notification of requirements--Extension of time...
Prospective review determinations--Timing--Notification of requirements--Extension of time.
For any prospective review determination, other than allowed by this section, a
health carrier shall make the determination and notify the covered person or, if applicable, the
covered person's authorized representative of the determination, whether the carrier certifies the
provision of the benefit or not, within a reasonable period of time appropriate to the covered person's
medical condition, but in no event later than fifteen days after the date the health carrier receives the
request. If the determination is an adverse determination, the health carrier shall make the
notification of the adverse determination in accordance with § 58-17H-32.
The time period for making a determination and notifying the covered person or, if applicable,
the covered person's authorized representative, of the determination pursuant to this section may be
extended once by the health carrier for up to fifteen days, if the health carrier:
Determines that an extension is necessary due to matters beyond the health carrier's
Notifies the covered person or, if applicable, the covered person's authorized
representative, prior to the expiration of the initial fifteen-day time period, of the
circumstances requiring the extension of time and the date by which the health carrier
expects to make a determination.
If the extension is necessary due to the failure of the covered person or the covered person's
authorized representative to submit information necessary to reach a determination on the request,
the notice of extension shall specifically describe the required information necessary to complete the
request and give the covered person or, if applicable, the covered person's authorized representative
at least forty-five days from the date of receipt of the notice to provide the specified information.
If the health carrier receives a prospective review request from a covered person or the covered
person's authorized representative that fails to meet the health carrier's filing procedures, the health
carrier shall notify the covered person or, if applicable, the covered person's authorized
representative of this failure and provide in the notice information on the proper procedures to be
followed for filing a request. This notice shall be provided as soon as possible, but in no event later
than five days following the date of the failure. The health carrier may provide the notice orally or,
if requested by the covered person or the covered person's authorized representative, in writing. The
provisions only apply in a case of failure that is a communication by a covered person or the covered
person's authorized representative that is received by a person or organizational unit of the health
carrier responsible for handling benefit matters and is a communication that refers to a specific
covered person, a specific medical condition or symptom, and a specific health care service,
treatment, or provider for which certification is being requested. (SL 2012, ch 239, § 1 provides:
"The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient
Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the
Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010)
is found to be unconstitutional in its entirety by a final decision of a federal court of competent
jurisdiction and all appeals exhausted or time for appeals elapsed.")
Source: SL 2011, ch 219, § 53.