Section 58-17C-86 - Issuance of decision--Required contents.
58-17C-86. Issuance of decision--Required contents. The decision issued pursuant to § 58-17C-85 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 the person or persons participating in the first level review process (the reviewers);
(2) A statement of the reviewers' understanding of the covered person's grievance;
(3) The reviewers' 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;
(4) A reference to the evidence or documentation used as the basis for the decision;
(5) For a decision involving an adverse determination:
(a) The specific reason or reasons for the adverse determination;
(b) A 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 § 58-17C-84, 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 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;
(e) 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; and
(f) If applicable, instructions for requesting:
(i) A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the 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;
(6) If applicable, a statement indicating:
(a) A description of the process to obtain an additional voluntary review of the first level review decision involving an adverse determination, if the covered person wishes to request a voluntary second level review pursuant to § 58-17C-85;
(b) The written procedures governing the voluntary review, including any required time frame for the review; and
(c) The covered person's right to bring a civil action in a court of competent jurisdiction;
(7) 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."; and
(8) 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 2003, ch 250, § 37.