58-17I-11. Issuance of decision--Required contents.

The decision issued pursuant to § 58-17I-9 shall set forth in a manner calculated to be understood by the covered person or, if applicable, the covered person's authorized representative and include the following:

(1)    The titles and qualifying credentials of any person participating in the first level review process (the reviewer);

(2)    Information sufficient to identify the claim involved with respect to the grievance, including the date of service, the health care provider, if applicable, the claim amount, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning;

(3)    A statement of the reviewer's understanding of the covered person's grievance;

(4)    The reviewer's decision in clear terms and the contract basis or medical rationale in sufficient detail for the covered person to respond further to the health carrier's position;

(5)    A reference to the evidence or documentation used as the basis for the decision;

(6)    For a first level review decision issued pursuant to § 58-17I-9 that upholds the grievance denial:

(a)    The specific reason or reasons for the final internal 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 reaching the denial;

(b)    The reference to the specific plan provisions on which the determination is based;

(c)    A statement that the covered person is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant, as the term relevant is defined in § 58-17I-8 to the covered person's benefit request;

(d)    If the health carrier relied upon an internal rule, guideline, protocol, or other similar criterion to make the final 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 final 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;

(e)    If the final 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; and

(f)    If applicable, instructions for requesting:

(i)    A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the final adverse determination, as provided in subsection (d) of this section; or

(ii)    The written statement of the scientific or clinical rationale for the determination, as provided in subsection (e) of this section;

(7)    If applicable, a statement indicating:

(a)    A description of the procedures for obtaining an independent external review of the final adverse determination pursuant to rules promulgated by the director; and

(b)    The covered person's right to bring a civil action in a court of competent jurisdiction;

(8)    If applicable, the following statement: "You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your state insurance director.";

(9)    Notice of the covered person's right to contact the Division of Insurance for assistance at any time, including the telephone number and address of the Division of Insurance.

Source: SL 2011, ch 219, § 83.

Commission Note: 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."