Utah Admin. Code 590-285-25

Current through Bulletin 2024-24, December 15, 2024

Section R590-285-25 - Independent Review of an Adverse Benefit Trigger Determination

(1)

(a) An insured or an insured's authorized representative may request an independent review of an insurer's adverse benefit trigger determination after an internal appeal process under Subsection R590-285-24(2) is exhausted.

(b) An insured or an insured's authorized representative may make a written request for an independent review within 180 days after the insurer's written notice of the final internal appeal decision is received by the insured and the insured's authorized representative, if applicable.

(c) The insurer shall bear the cost of an independent review.

(2)

(a) Within five business days of receiving a written request for an independent review, an insurer shall refer the request to an independent review organization.

(i) The insurer shall choose an independent review organization approved by the commissioner.

(ii) The insurer shall vary its selection of authorized independent review organization on a rotating basis.

(b) An insurer shall refer the request for independent review of an adverse benefit trigger determination to an independent review organization, subject to the following:

(i) the independent review organization shall be on a list of approved independent review organizations that satisfy the requirements of a qualified long-term care insurance independent review organization under this section;

(ii) the independent review organization may not have a conflict of interest with the insured, the insured's authorized representative, if applicable, or the insurer; and

(iii) the review is limited to the information or documentation provided to and considered by the insurer in making its determination, including any information or documentation considered as part of the internal appeal process.

(3) If the insured or the insured's authorized representative has new or additional information not previously provided to the insurer, whether submitted to the insurer or the independent review organization, the information shall first be considered in the insurer's internal review process under Subsection R590-285-24(2).

(a) While the new or additional information is being reviewed by the insurer, the independent review organization shall suspend its review and stay the time period for review until the insurer completes its review.

(b) The insurer shall complete its review of the new or additional information and provide written notice of its decision to the insured and the insured's authorized representative, if applicable, and the independent review organization within five business days of the insurer's receipt of the new or additional information.

(i) If the insurer maintains its denial after the review, the independent review organization shall continue its review and make its decision within the time period specified in this section.

(ii) If the insurer overturns its decision following its review of the new or additional information, the independent review request is considered withdrawn.

(4)

(a) An insurer shall acknowledge, in writing, to the insured and the insured's authorized representative, if applicable, and the commissioner that the request for an independent review has been received, accepted, and forwarded to an independent review organization.

(b) The notice shall include the name and address of the independent review organization.

(5)

(a) Within five business days of receipt of a request for an independent review, the independent review organization assigned shall notify the insured and the insured's authorized representative, if applicable, and the insurer, that it accepted the independent review request and identify the type of licensed health care professional assigned to the review.

(b) The assigned independent review organization shall include in the notice a statement that the insured or the insured's authorized representative may submit, in writing, to the independent review organization, within seven days following the date of receipt of the notice, additional information and supporting documentation that the independent review organization shall consider when conducting its review.

(6)

(a) The independent review organization shall:

(i) review all information and documents provided to the independent review organization; and

(ii) provide copies of any documentation or information provided by the insured or the insured's authorized representative to the insurer for its review, if it is not part of the information or documentation submitted by the insurer to the independent review organization.

(b) The insurer shall review the information and provide its analysis of new information submitted under this Subsection (6).

(7)

(a) During the independent review process, the insured or the insured's authorized representative may submit new or additional information not previously provided to the insurer that is pertinent to the benefit trigger denial.

(b) The insurer shall consider any new or additional information and affirm or overturn its benefit trigger determination.

(c) If the insurer affirms its benefit trigger determination, the insurer shall promptly provide the new or additional information to the independent review organization for its review, along with the insurer's analysis of the information.

(d) If the insurer overturns its benefit trigger determination:

(i) the insurer shall provide notice of its decision to the independent review organization, the insured, and the insured's authorized representative, if applicable; and

(ii) the independent review process shall immediately cease.

(8)

(a) An independent review organization shall provide the insured and the insured's authorized representative, if applicable, and the insurer written notice of its decision within 30 days from receipt of the referral.

(b) If an independent review organization overturns the insurer's decision, it shall:

(i) establish the precise date within the specific time period under review that the benefit trigger is determined to have been met; and

(ii) specify the specific time period under review that the insurer declined eligibility, but during which the independent review organization determines the benefit trigger was met.

(c) The decision of the independent review organization regarding whether the insured met the benefit trigger is final and binding on the insurer.

(d) The independent review organization's determination shall be used solely to establish liability for benefit trigger decisions and is admissible in a proceeding to the extent that it establishes the eligibility of benefits payable.

(9) This section may not restrict the insured's right to submit a new request for a benefit trigger determination after the independent review decision, if the independent review organization upholds the insurer's decision.

(10) The commissioner shall maintain and periodically update a list of qualified independent review organizations.

(a) To qualify as an independent review organization for limited long-term care insurance, an independent review organization shall demonstrate to the satisfaction of the commissioner that it is unbiased and meets the following qualifications:

(i) have on staff, or contract with, a qualified and licensed health care professional in an appropriate field for determining an insured's functional or cognitive impairment to conduct the review;

(ii) the independent review organization or any of its licensed health care professionals may not, in any manner:

(A) be related to or affiliated with an entity that previously provided medical care to the insured;

(B) receive compensation of any type that is dependent on the outcome of the review; or

(C) use a licensed health care professional who is an employee of the insurer or related in any manner to the insured.

(b) An independent review organization shall provide to the commissioner:

(i) a description of the fees charged for an independent review of a limited long-term care insurance benefit trigger decision that are reasonable and customary for the type of limited long-term care insurance benefit trigger decision under review;

(ii) the name of the medical director or health care professional responsible for the supervision and oversight of the independent review process;

(iii) a description of the qualifications of each reviewer retained to conduct an independent review, including the reviewer's:

(A) current and past employment history;

(B) current and past practice affiliations; and

(C) past experience with decisions relating to:

(I) long-term care;

(II) functional capacity;

(III) dependency in activities of daily living; and

(IV) assessing cognitive impairment;

(iv) a description of the procedures used to ensure reviewers are:

(A) appropriately licensed, registered, or certified;

(B) trained in the principles, procedures, and standards of the independent review organization; and

(C) knowledgeable about the functional or cognitive impairments associated with the diagnosis and disease staging processes, including expected duration of such impairment;

(v) the number of reviewers retained by the independent review organization and a description of the areas of expertise for each reviewer, including the types of cases a reviewer is qualified to review;

(vi) a description of the policies and procedures employed to protect the confidentiality of protected health information, in accordance with federal and state law;

(vii) a description of the independent review organization's quality assurance program;

(viii) the names of all corporations and organizations owned or controlled by the independent review organization, or that own or control the organization, and the nature and extent of any such ownership or control; and

(ix) the names and resumes of all directors, officers, and executives.

(c) The commissioner shall accept another state's certification of an independent review organization if the state requires the independent review organization to meet qualifications that are substantially similar to the qualifications in this section.

(11) A certified independent review organization shall:

(a) maintain written documentation, in an easily accessible and retrievable form, for the year it received the information, plus three calendar years, establishing:

(i) the date it receives a request for independent review;

(ii) the date each review is conducted;

(iii) the resolution;

(iv) the date the resolution was communicated to the insurer and the insured; and

(v) the name and professional status of the reviewer conducting the review;

(b) document the measures taken to safeguard the confidentiality of the records and prevent unauthorized use and disclosures;

(c) report annually to the commissioner by June 1 for the previous calendar year, in the aggregate and for each limited long-term care insurer, the following:

(i) the total number of requests received for an independent review of limited long-term care benefit trigger decisions;

(ii) the total number of reviews conducted;

(iii) the resolution of the reviews;

(iv) the number of reviews withdrawn before review; and

(v) the percentage of reviews conducted within the prescribed time frame under Section R590-285-25; and

(d) report immediately to the commissioner any change in status that would cause the certified independent review organization to cease meeting any of the qualifications required of an independent review organization performing independent reviews of limited long-term care benefit trigger decisions.

(12) This section may not limit the ability of an insurer to assert a right the insurer has under a policy related to:

(a) an insured's misrepresentation;

(b) changes in the insured's benefit eligibility; or

(c) terms, conditions, and exclusions of the policy, other than failure to meet the benefit trigger.

Utah Admin. Code R590-285-25

Adopted by Utah State Bulletin Number 2021-05, effective 2/23/2021

Adopted by Utah State Bulletin Number 2024-21, effective 10/22/2024