sb 0109

CHAPTER 207

SB 109 - FINAL VERSION

AN ACT implementing certain federal regulations relative to setting minimum requirements for employee benefit plan procedures pertaining to the filing of benefit claims, notification of benefit determinations, and appeal of adverse benefit determinations.

SPONSORS: Sen. Wheeler, Dist 21; Rep. M. Fuller Clark, Rock 36

This bill implements certain regulations relative to setting minimum requirements for employee benefit plan procedures pertaining to the filling of benefit claims, notification of benefit determinations, and appeal of adverse benefit determinations.

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Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.

Be it Enacted by the Senate and House of Representatives in General Court convened:

207:1 New Paragraphs; Definitions Added. Amend RSA 415-A:1 by inserting after paragraph I the following new paragraphs:

I-a. "Claim denial" means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant's or beneficiary's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.

I-b. "Claim involving urgent care" means any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations:

(a) Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or

(b) In the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

I-c. "Claimant's representative" shall mean an individual authorized by a claimant in writing to pursue a claim or appeal on the claimant's behalf.

I-d. "Employee benefit plan" means employee benefit plans described in section 4(a) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1133 and 1135 and not exempted under section 4(b) of this Act.

207:2 New Paragraphs; Definitions Added. Amend RSA 415-A:1 by inserting after paragraph III the following new paragraphs:

IV. "Post-service claim" means any claim for a health or disability benefit to which the terms of the plan do not condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining the medical care or disability benefit. "Post-service claim" shall not include a request for reimbursement made by a provider pursuant to the terms of an agreement between the provider and the health carrier.

V. "Pre-service claim" means any claim for a benefit under a health plan with respect to which the terms of the plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care. "Pre-service claim" shall not include a request for reimbursement made by a provider pursuant to the terms of an agreement between the provider and the health carrier.

207:3 New Sections; Minimum Standards for Claim Review; Accident and Health Insurance. Amend RSA 415-A:4 by inserting after section 4 the following new sections:

415-A:4-a Minimum Standards for Claim Review; Accident and Health Insurance. Any carrier that offers group health plans, employee benefit plans, and disability plans shall establish and maintain written procedures by which a claimant may obtain a determination of claims and by which a claimant may appeal a claim denial.

I. The procedures for determination of a claim shall meet the following minimum standards:

(a) The plan shall maintain a toll-free telephone number to ensure that a representative of the plan shall be accessible by telephone to insureds, patients, and claimant's representatives as required to meet the response times specified herein.

(b) Clinical review criteria considered or utilized in making claim benefit determinations shall be:

(1) Developed with input from appropriate actively practicing practitioners in the licensed entity's service area;

(2) Updated at least biennially and as new treatments, applications, and technologies emerge;

(3) Developed in accordance with the standards of national accreditation entities;

(1) The specific reason or reasons for the determination and shall refer to the specific provision of the policy or plan on which the determination is based;

(2) A statement of the claimant's or the representative of the claimant's right to access the internal grievance process and the process for obtaining external review. The notification shall also include a written explanation of any claim denial, with the name and credentials of the carrier or other licensed entity medical director, including board status and the state or states where the person is currently licensed, and the relevant clinical rationale used to make the claim denial. If the person making the claim denial is not the medical director but a designee, then the credentials, board status, and state or states of current license shall also be provided for that person. Nothing in this section shall be construed to require a carrier or other licensed entity to provide proprietary information protected by third party contracts;

(3) If an internal rule, guideline, protocol, or other similar provision was relied upon in making the benefit determination, a reference to the specific rule, guideline, protocol, or other similar provision; and a statement that such a rule, guideline, protocol, or other similar provision was relied upon in making the claim denial and that a copy of such rule, guideline, protocol, or other provision will be provided free of charge to the claimant or claimant's representative upon request;

(4) If the claim denial is based on a medical necessity or experimental treatment or other similar exclusion or limit, an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan or the policy to the claimant's medical circumstances;

(5) Any clinical review criteria that are used by the carrier or other licensed entity as the basis of a determination shall be disclosed to the treating provider and the claimant. Such disclosure shall be accompanied by the following notice: "The materials provided to you are criteria used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract;" and

(6) A description of the plan's grievance procedures and the time limits applicable to such procedures. In the case of a denial of a benefit concerning a claim involving urgent care or in the case of a denial of a claim related to continuation of an ongoing course of treatment for a person who has received emergency services, but who has not been discharged from a facility, a description of the expedited review applicable to such a claim shall be included in the determination. For all other claim benefit determinations, a description of the grievance process shall be specifically described in the determination.

II. Notification of a claim denial shall be made within the following time periods:

(a) The determination of a claim involving urgent care shall be made as soon as possible, taking into account the medical exigencies, but in no event later than 72 hours after receipt of the claim, unless the claimant or claimant's representative fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable. In the case of such failure, the licensee shall notify the claimant or claimant's representative within 24 hours of receipt of the claim and shall advise the claimant or claimant's representative of the specific information necessary to determine the claim. The 72-hour period shall be tolled until such time as the claimant submits the required information.

(b) The determination of a claim involving urgent care and relating to the extension of an ongoing course of treatment and involving a question of medical necessity shall be made within 24 hours of receipt of the claim, provided that the claim is made at least 24 hours prior to the expiration of the prescribed period of time or course of treatment. In the event the claimant or claimant's representative fails to provide sufficient notice or sufficient information, the licensee shall notify the claimant or claimant's representative within 24 hours of the receipt of the claim and shall advise the claimant or claimant's representative of the specific information necessary to determine the claim. If the determination relates to a reduction or termination of coverage for a course of treatment beyond the end of the period of time or number of treatments previously approved, coverage for the services shall not be terminated during the pendency of the determination proceeding.

(c) The determination of all other claims for preservice benefits shall be made within a reasonable time period, but in no event more than 15 days after receipt of the claim, unless the claimant or claimant's representative fails to provide sufficient information to determine whether, or to what extent, benefits are covered as payable. In the case of such failure, the licensee shall notify the claimant or claimant's representative within 5 days of receipt of the claim. The 15-day period shall be tolled until such time as the claimant or claimant's representative submits the required information.

(d) The determination of a post service claim shall be made within 30 days of the date of filing. In the event the claimant fails to provide sufficient information to determine the claim, the carrier shall notify the claimant within 15 days as to what additional information is required to process the claim and the claimant shall be given at least 45 days to provide the required information. The 30-day period for claim determination shall be tolled until such time as the claimant submits the required information.

III. Any carrier or other licensed entity that offers group health plans, employee benefit plans, and disability plans shall file with the department a copy of its claim determination procedure, including all forms used, and a copy of the materials designed to inform its members or insureds of the requirements of the claim determination and grievance procedure and the responsibilities and rights of the members or insureds under the plan each year. The carrier shall also file an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed.

IV. In any request for a benefit determination, the claimant may authorize a representative to pursue the claim or benefit determination by submitting a written statement to the licensed entity that acknowledges the representation.

V. No fees or costs shall be assessed against a claimant related to a request for claim benefit determination.

415-A:4-b Appeal Procedure. Every carrier or other licensed entity which offers group health insurance, employee benefit plans, or disability benefits shall file with the insurance department, by April 1 of each year, and shall maintain a written procedure by which a claimant, or a representative of the claimant, shall have a reasonable opportunity to appeal a claim denial to the carrier or other licensed entity, and under which there shall be a full and fair review of the claim denial. The written procedure filed with the insurance department shall include all forms used to process an appeal.

(a) The person or persons reviewing the grievance shall not be the same person or persons making the initial determination, shall not be subordinate to or the supervisor of the person making the initial determination, and shall act as a fiduciary;

(b) The person reviewing the grievance on a first or second level appeal shall have appropriate medical and professional expertise and credentials to competently render a determination on appeal;

(c) The claimant or claimant's representative shall have at least 180 days following receipt of a notification of an adverse claim determination to appeal;

(d) The claimant or claimant's representative shall have an opportunity to submit written comments, documents, records, and other information relating to the claim without regard to whether those documents or materials were considered in making the initial determination;

(e) The claimant or claimant's representative shall be provided upon request, and without charge, reasonable access to, and copies of all documents, records, and other information relevant to or considered in making the initial adverse claim determination; and

(f) The review shall be a de novo proceeding and shall consider all information, documents, or other material submitted in connection with the appeal without regard to whether the information was considered in making the claim denial.

II. In the appeal of a claim denial that is based in whole or in part on a medical judgment:

(a) The review shall be conducted by or in consultation with a health care professional who has appropriate training and experience in the field of medicine;

(b) The titles and qualifying credentials of the person conducting the review shall be included in the decision; and

(c) The identity and qualifications of any medical or vocational expert whose advice was considered, without regard to whether it was relied upon in making the initial claim denial, shall be made available to the claimant upon request.

III. In the appeal of a claim for urgent care, a claim involving a matter that would seriously jeopardize the life or health of a covered person or would jeopardize the covered person's ability to regain maximum function, or a claim concerning an admission, availability of care, or the continued stay or health care service for a person who has received emergency services, but who has not been discharged from a facility, an expedited appeal process shall be made available which shall provide for:

(a) The submission of information by the claimant to the carrier by telephone, facsimile, or other expeditious method; and

(b) The determination of the appeal shall be made not more than 72 hours after the submission of the completed request for appeal.

(a) In the case of nonexpedited appeal of a pre-service claim or a post-service claim, the determination on appeal shall be made within a reasonable time appropriate to the medical circumstances, but in no event more than 30 days after receipt by the carrier or other licensed entity of the claimant's appeal.

(b) In the case of an expedited appeal related to an urgent care claim, a carrier or other licensed entity shall make a decision and notify the covered person as expeditiously as the covered person's medical condition requires, but in no event more than 72 hours after the appeal is filed. If the expedited review involves ongoing urgent care services, the service shall be continued without liability to the covered person until the covered person has been notified of the determination. A carrier or other licensed entity shall provide written confirmation of its decision concerning an expedited review within 2 business days of providing notification of that decision, if the initial notification was not in writing.

(c) The period of time within which a decision shall be rendered on appeal shall begin to run at the time the appeal is filed in accordance with the appeal procedures of the carrier or other licensed entity, without regard to whether all the information necessary to make a determination on appeal is contained in the filing. In the event the claimant fails to submit information necessary to decide the appeal, the period for making the determination on appeal shall be tolled from the date the claimant is notified in writing of what additional information is required until the date the claimant responds to the request. The carrier or other licensed entity shall provide notification of incompleteness as soon as possible; but in no event more than 24 hours after the filing of the appeal in appeals involving urgent care. In the event that the claimant fails, within a 45-day period from the date of notification, to provide sufficient information, the carrier may deny the appeal on the basis of incompleteness. The appeal may be reopened upon receipt of the required information.

(a) The carrier or other licensed entity shall provide a claimant with a written determination of the appeal that shall include:

(1) The specific reason or reasons for the determination, including reference to the specific provision, rule, protocol, or guideline on which the determination is based;

(2) A statement that the rule, protocol, or guideline governing the appeal will be provided without charge to the claimant upon request;

(3) A statement describing all other dispute resolution options available to the claimant, including, but not limited to other options for internal review and options for external review, and options for bringing a legal action;

(4) A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits;

(5) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the claim denial, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the claim denial, and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to the claimant upon request;

(6) If the claim denial is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the denial, applying the terms of the plan to the claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request;

(7) 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 local U.S. Department of Labor Office and your state insurance regulatory agency;" and

(8) A statement describing the claimant's right to contact the insurance commissioner's office for assistance which shall include a toll-free telephone number and address of the commissioner.

(b) A carrier or other licensed entity that offers group health plans, employee benefit plans, or disability plans shall file with the commissioner a certificate of compliance by, April 1 of each year, stating that the carrier or other licensed entity has established and maintained, for each of its health benefit plans, grievance procedures that fully comply with the provisions of this chapter. Material modifications to the procedure shall be filed with the commissioner prior to becoming effective.

(c) A carrier or other licensed entity that offers group health plans, employee benefit plans, or disability plans shall maintain written records documenting all grievances and appeals received during a calendar year, a general description of the reason for the appeal or grievance, the name of the claimant, the dates of the appeal or grievance and the date of resolution.

(d) A carrier or other licensed entity that offers group health plans, employee benefit plans, or disability plans shall provide to consumers:

(1) A description of the internal grievance procedure for claim determinations and other matters. The description shall be set forth in or attached to the policy, certificate, membership booklet, or other evidence of coverage provided to covered persons;

(2) A statement of a covered person's right to contact the commissioner's office for assistance at any time. The statement shall include the toll-free telephone number and address of the commissioner; and

(3) A statement that the carrier or other licensed entity will provide assistance in preparing an appeal of an adverse benefit determination, and a toll-free telephone number to contact the carrier or other licensed entity.

(e) In any case where a carrier or other licensed entity that offers group health plans, employee benefit plans, or disability plans provides 2 levels of appeal for the pre-service claim determinations, the first level shall be completed within 15 days and the second level completed within the 30-day time period beginning from the initial date of filing the appeal or grievance. With respect to a second level appeal involving a claim for continuation of services or urgent care, the carrier or other licensed entity shall make a decision and notify the claimant within 72 hours after the second level appeal is filed. For second level appeals involving a post-service claim, the carrier shall make a decision and notify the claimant within 60 days of the date the appeal was filed.

(f) Annual reports shall be made to the insurance commissioner regarding plan complaints, claim denials, and prior authorization statistics in such form and containing such information as the commissioner may prescribe by rule or otherwise.

VI. In an appeal of a claim denial or other matter, the claimant may authorize a representative to pursue a claim or an appeal by submitting a written statement to the carrier or other licensed entity that acknowledges the representation.

VII. No fees or costs shall be assessed against a claimant related to a request for a grievance or appeal.

207:4 New Paragraph; Definition Added. Amend RSA 420-E:1 by inserting after paragraph I the following new paragraph:

I-a. "Claim involving urgent care" means any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations:

(a) Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or

207:5 New Paragraph; Definition Added. Amend RSA 420-E:1 by inserting after paragraph III the following new paragraph:

III-a. "Pre-service claim" means any claim for a benefit under a health plan with respect to which the terms of the plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.

207:6 Licensure of Medical Utilization Review Entities; Minimum Standards. RSA 420-E:4 is repealed and reenacted to read as follows:

420-E:4 Minimum Standards; Licensure of Medical Utilization Review Entities. All licensees shall establish and maintain a utilization review procedure by which a claimant or claimant's representative may seek a claim benefit determination. The procedure shall meet the following minimum standards:

I. The licensee shall maintain a toll-free telephone number to ensure that a representative of the licensee shall be accessible by telephone to insureds, patients, and providers 7 days a week during normal working hours.

II. Claim benefit determinations shall be made by a licensed or certified health care provider.

III. Clinical review criteria considered or utilized in making claim benefit determinations shall be:

(a) Developed with input from appropriate actively practicing practitioners in the carrier or other licensed entity's service area;

(b) Updated at least biennially and as new treatments, applications, and technologies emerge;

IV. Notification of claim benefit determinations shall be made within the following time periods:

(b) The determination of a claim relating to the extension of an ongoing course of treatment and involving a question of medical necessity shall be made within 24 hours of receipt of the claim, provided that the claim is made at least 24 hours prior to the expiration of the prescribed period of time or course of treatment. In the event the claimant or claimant's representative fails to provide sufficient notice or sufficient information, the licensee shall notify the claimant or claimant's representative within 24 hours of the receipt of the claim and shall advise the claimant or claimant's representative of the specific information necessary to determine the claim. Services shall not be terminated during the pendency of the determination proceeding.

(c) The determination of all other claims for benefits shall be made within a reasonable time period, but in no event more than 15 days after receipt of the claim, unless the claimant or claimant's representative fails to provide sufficient information to determine whether, or to what extent, benefits are covered as payable. In the case of such failure, the licensee shall notify the claimant or claimant's representative within 5 days of receipt of the claim. The 15-day period shall be tolled until such time as the claimant or claimant's representative submits the required information.

V. The manner and content of notification of claim benefit determinations shall be as follows:

(a) The licensee shall notify the claimant or claimant's representative in writing or electronically of the claim determination.

(b) The notification shall state the specific reason or reasons for the determination and shall refer to the specific provision of the policy or plan on which the determination is based.

(c) The notification shall include a statement of the claimant's right or the right of the claimant's representative to access the internal grievance process and the process for obtaining external review. The notification shall also include a written explanation of any claim denial, with the name and credentials of the carrier or other licensed entity medical director; including board status and the state or states where the person is currently licensed, and the relevant clinical rationale used to make the claim denial. If the person making the claim denial is not the medical director but a designee, then the credentials, board status, and state or states of current license shall also be provided for that person. Nothing in this section shall be construed to require a carrier or other licensed entity to provide proprietary information protected by third party contracts.

(d) If an internal rule, guideline, protocol, or other similar provision was relied upon in making the benefit determination, the determination shall reference the specific rule, guideline, protocol, or other similar provision; and shall include a statement that such a rule, guideline, protocol, or other similar provision was relied upon in making the claim denial and that a copy of such rule, guideline, protocol, or other provision will be provided free of charge to the claimant or claimant's representative upon request.

(e) If the claim denial is based on a medical necessity or experimental treatment or other similar exclusion or limit, the determination shall include an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan or the policy to the claimant's medical circumstances.

(f) Any clinical review criteria that are used by the carrier or other licensed entity or its designee utilization review entity as the basis of an claim denial shall be disclosed to the treating provider and the claimant. Such disclosure shall be accompanied by the following notice: "The materials provided to you are criteria used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract."

(g) In the case of a denial of a benefit concerning a claim involving urgent care or in the case of a denial of a claim related to continuation of an ongoing course of treatment for a person who has received emergency services, but who has not been discharged from a facility, a description of the expedited review applicable to such a claim shall be included in the determination. For all other claim benefit determinations, a description of the grievance process shall be specifically described in the determination.

VI. A licensee shall file with the department a copy of the materials designed to inform patients of the requirements of the utilization plan and the responsibilities and rights of patients under the plan and an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed.

VII. In any request for a benefit determination, the claimant may authorize a representative to pursue the claim or benefit determination by submitting a written statement to the licensee that acknowledges the representation.

VIII. No fees or costs shall be assessed against a claimant related to a request for claim benefit determination.

420-E:6 Periodic Reviews. The commissioner or [~~his~~] designee may conduct periodic reviews of the operations of the entities licensed under this chapter to ensure that they continue to meet the minimum standards set in RSA 420-E:4 and any applicable rules adopted by the commissioner. The commissioner may perform periodic telephone audits of licensees to determine if representatives of the licensee are reasonably accessible, as required in RSA 420-E:4, [~~III~~] I.

III. The time period for notification of determination as required under RSA 420-E:4, [I] IV.

IV. Standards for telephone accessibility as required under RSA 420-E:4, [~~III~~] I.

207:10 New Paragraphs; Definitions. Amend RSA 420-J:3 by inserting after paragraph V the following new paragraphs:

V-a. "Claim involving urgent care" means any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations:

(a) Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or

V-b. "Claimant's representative" shall mean an individual authorized by a claimant in writing to pursue a claim or appeal on the claimant's behalf.

207:11 New Paragraphs; Definitions. Amend RSA 420-J:3 by inserting after paragraph XXVIII the following new paragraphs:

XXVIII-a. "Post service claim" means any claim for a health or disability benefit to which the terms of the plan do not condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining the medical care or disability benefit. "Post-service claim" shall not include a request for reimbursement made by a provider pursuant to the terms of an agreement between the provider and the health carrier.

XXVIII-b. "Pre-service claim" means any claim for a benefit under a health plan with respect to which the terms of the plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care. "Pre-service claim" shall not include a request for reimbursement made by a provider pursuant to the terms of an agreement between the provider and the health carrier.

207:12 Grievance Procedures. RSA 420-J:5 is repealed and reenacted to read as follows:

420-J:5 Grievance Procedures. Every carrier or other licensed entity shall establish and shall maintain a written procedure by which a claimant or a representative of the claimant, shall have a reasonable opportunity to appeal a claim denial to the carrier or other licensed entity, and under which there shall be a full and fair review of the claim denial. The written procedure filed with the insurance department shall include all forms used to process an appeal.

(a) The persons reviewing the grievance shall not be the same person or persons making the initial determination, and shall not be subordinate to or the supervisor of the person making the initial determination;

(b) The person reviewing the grievance on a first or second level appeal have appropriate medical and professional expertise and credentialing to competently render a determination on appeal;

(d) The claimant shall have an opportunity to submit written comments, documents, records, and other information relating to the claim without regard to whether those documents or materials were considered in making the initial determination;

(e) The claimant shall be provided upon request, and without charge, reasonable access to, and copies of all documents, records, and other information relevant to or considered in making the initial adverse claim determination; and

II. In the appeal of a claim denial that is based in whole or in part on a medical judgment:

(a) The review shall be conducted by or in consultation with a health care professional who has appropriate training and experience in the field of medicine;

(b) The titles and qualifying credentials of the person conducting the review shall be included in the decision; and

III. In the appeal of a claim for urgent care, a claim involving a matter that would seriously jeopardize the life or health of a covered person or would jeopardize the covered person's ability to regain maximum function, or a claim concerning an admission, availability of care, continued stay or health care service for a person who has received emergency services, but who has not been discharged from a facility, an expedited appeal process shall be made available which shall provide for:

(a) The submission of information by the claimant to the carrier by telephone, facsimile, or other expeditious method; and

(b) The determination of the appeal not more than 72 hours after the submission of the request for appeal.

(a) In the case of nonexpedited appeal of a pre-service claim or post-service claim, the determination on appeal shall be made within a reasonable time appropriate to the medical circumstances, but in no event more than 30 days after receipt by the carrier or other licensed entity of the claimant's appeal.

(b) In the case of an expedited appeal related to an urgent care claim, a carrier or other entity shall make a decision and notify the covered person as expeditiously as the covered person's medical condition requires, but in no event more than 72 hours after the appeal is filed. If the expedited review involves ongoing urgent care services, the service shall be continued without liability to the covered person until the covered person has been notified of the determination. A carrier or other licensed entity shall provide written confirmation of its decision concerning an expedited review within 2 business days of providing notification of that decision, if the initial notification was not in writing.

(c) The period of time within which a decision shall be rendered on appeal shall begin to run at the time the appeal is filed in accordance with the appeal procedures of the carrier or other licensed entity, without regard to whether all the information necessary to make a determination on appeal is contained in the filing. In the event the claimant fails to submit information necessary to decide the appeal, the period for making the determination on appeal shall be tolled from the date the claimant is notified in writing of precisely what is required until the date the claimant responds to the request. The carrier or other licensed entity shall provide notification of incompleteness as soon as possible; but in no event more than 24 hours after the filing of the appeal in appeals involving urgent care. In the event that the claimant fails, within a 45-day period from the date of notification, to provide sufficient information, the carrier may deny the appeal on the basis of incompleteness. The appeal may be reopened upon receipt of the required information.

(a) The carrier or other licensed entity shall provide a claimant with a written determination of the appeal that shall include:

(1) The specific reason or reasons for the determination, including reference to the specific provision, rule, protocol, or guideline on which the determination is based;

(2) A statement that the rule, protocol, or guideline governing the appeal will be provided without charge to the claimant upon request;

(5) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the claim denial, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the claim denial and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to the claimant upon request;

(8) A statement describing the claimant's right to contact the insurance commissioner's office for assistance which shall include the toll-free telephone number and address of the commissioner.

(b) A carrier or other licensed entity that offers group health plans, employee benefit plans, or disability plans shall file annually with the commissioner, as part of its annual report required by RSA 420-J:5, V(g), a certificate of compliance stating that the carrier or other licensed entity has established and maintained, for each of its health benefit plans, grievance procedures that fully comply with the provisions of this chapter. Material modifications to the procedure shall be filed with the commissioner prior to becoming effective.

(d) A carrier or other licensed entity that offers group health plans, employee benefit plans, or disability plans shall provide to consumers:

(1) A description of the internal grievance procedure required under RSA 420-J:5 for claim denials and other matters and a description of the process for obtaining external review under RSA 420-J:5-a - RSA 420-J:5-e. These descriptions shall be set forth in or attached to the policy, certificate, membership booklet, or other evidence of coverage provided to covered persons.

(e) In any case where a carrier or other licensed entity provides 2 levels of appeal, the first level shall be completed within 15 days and the second level completed within the 30-day time period beginning from the initial date of filing the appeal or grievance. With respect to a second level appeal involving a claim for continuation of services or urgent care, the carrier or other licensed entity shall make a decision and notify the claimant within 72 hours after the second level appeal is filed. For appeals involving post service claims, the carrier shall make a decision and notify the claimant within 60 days of the date the completed appeal was filed.

(f) Annual reports shall be made to the insurance commissioner regarding plan complaints, adverse determinations, claim denials, and prior authorization statistics in such form and containing such information as the commissioner may prescribe by rule or otherwise.

(g) If the claimant has filed an appeal and the carrier or other licensed entity has not issued a decision within the required time frames, the carrier or other licensed entity shall promptly provide the claimant with a statement of the claimant's right to file an external appeal as provided in RSA 420-J:5-a - RSA 420-J:5-e. The statement of appeal rights shall include a description of the process for obtaining external review of a determination, a copy of the written procedures governing external review, including the required time frames for requesting external review, and notice of the conditions under which expedited external review is available.

VII. No fees or costs shall be assessed against a claimant related to a request for a grievance or appeal.

207:13 Utilization Review. RSA 420-J:6, III is repealed and reenacted as follows:

III. Notification of a claim denial shall be made within the following time periods:

(c) The determination of all other claims for pre-service benefits shall be made within a reasonable time period, but in no event more than 15 days after receipt of the claim, unless the claimant or claimant's representative fails to provide sufficient information to determine whether, or to what extent, benefits are covered as payable. In the case of such failure, the licensee shall notify the claimant or claimant's representative within 5 days of receipt of the claim. The 15-day period shall be tolled until such time as the claimant or claimant's representative submits the required information.

207:14 New Paragraph; Definition Added. Amend RSA 420-J:3 by inserting after paragraph V the following new paragraph:

V-a. "Claim denial" means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant's or beneficiary's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.

(b) The covered person has completed the internal review procedures provided by the carrier or other licensed entity pursuant to RSA 420-J:5, [~~III through VI,~~] or the carrier or other entity has agreed to submit the determination to independent external review prior to completion of internal review, or the covered person has requested first or second level, standard or expedited review and has not received a decision from the carrier or other licensed entity within the required time frames;

(c) The covered person or the covered person's authorized representative has submitted the request for external review in writing to the commissioner within 180 days of the date of the carrier or other licensed entity's second level denial decision provided pursuant to RSA 420-J:5, [~~V or VI,~~] or if the carrier or other licensed entity has failed to make a first or second level, standard or expedited review decision that is past due, within 180 days of the date the decision was due;

VI. For companies or insurers providing health insurance through a managed care system of health care delivery or reimbursement, a description of the grievance procedures as required pursuant to RSA 420-J:5[~~, II(a)~~].