Section Ins 8001.06 - Required Claim Provisions(a) Health carriers that offer FMLI shall establish and maintain reasonable procedures governing the filing of benefit claims, notification of benefit determinations, and appeal of adverse benefit determinations, hereinafter collectively referred to as claims procedures.(b) Individual policies and group certificates shall include a description of the process for appealing and resolving adverse benefit determinations which comply with Ins 1001. If applicable to the employer plan sponsor, the process shall comply with procedures under the Employee Retirement Income Security Act of 1974.(c) The carrier shall provide a claimant with written or, if requested by the claimant, electronic notification of any adverse benefit determination.(d) The notification of any adverse benefit determination shall set forth, in a manner calculated to be understood by the claimant:(1) The specific reason or reasons for the adverse determination;(2) Reference to the specific policy provisions on which the determination is based;(3) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary; and(4) A description of the carrier's review procedures and the time limits applicable to such procedures, including a statement of the claimant's right to bring a civil action following an adverse benefit determination on review.N.H. Admin. Code § Ins 8001.06
Derived from Number 2, Filed January 12, 2023, Proposed by #13499, Effective 11/30/2022, Expires 11/30/2032