Insurance, Administration

Rule R590-192

Unfair Accident and Health Claims Settlement Practices

Change in Proposed Rule

DAR File No.: 35103
Filed: 10/14/2011 11:40:53 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rule is being changed to comply with changes in federal regulations, Technical Release number 2011-02 from the Department of Labor.

Summary of the rule or change:

The requirement to make urgent care decisions within 24 hours is being reversed to 72 hours. (DAR NOTE: This change in proposed rule has been filed to make additional changes to a proposed amendment that was published in the August 15, 2011, issue of the Utah State Bulletin, on page 32. Underlining in the rule below indicates text that has been added since the publication of the proposed rule mentioned above; strike-out indicates text that has been deleted. You must view the change in proposed rule and the proposed amendment together to understand all of the changes that will be enforceable should the agency make this rule effective.)

State statutory or constitutional authorization for this rule:

• Section 31A-2-201
• Section 31A-1-301
• Section 31A-2-308
• Section 31A-2-204
• Section 31A-26-303
• Section 31A-21-312

Anticipated cost or savings to:

the state budget:

This change will have no fiscal impact on the department. It will not affect filings made to the department or its revenues and expenses.

local governments:

The change to this rule will have no impact on local government since the rule deals solely with the information being provided by a medical provider to the insurance company.

small businesses:

The change to this rule affects decisions made by insurance companies who are large employers.

persons other than small businesses, businesses, or local governmental entities:

The change provides insurers with an additional 48 hours to make urgent care claim decisions. This was the requirement prior to 06/30/2011 when the requirement was changed to 24 hours. The department is not aware of any fiscal impact this may have on consumers, insurers, or medical providers.

Compliance costs for affected persons:

The change provides insurers with an additional 48 hours to make urgent care claim decisions. This was the requirement prior to 06/30/2011 when the requirement was changed to 24 hours. The department is not aware of any fiscal impact this may have on consumers, insurers, or medical providers.

Comments by the department head on the fiscal impact the rule may have on businesses:

The changes to this rule should have no fiscal impact on those involved in urgent care claims issues. It is a procedural change.

Neal T. Gooch, Commissioner

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Insurance
Administration
Room 3110 STATE OFFICE BLDG
450 N MAIN ST
SALT LAKE CITY, UT 84114-1201

Direct questions regarding this rule to:

• Jilene Whitby at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

12/01/2011

Interested persons may attend a public hearing regarding this rule:

• 11/15/2011 11:00 AM, State Office Bldg, 450 N State Street, Room 3112, Salt Lake City, UT

This rule may become effective on:

12/08/2011

Authorized by:

Jilene Whitby, Information Specialist

R590. Insurance, Administration.

R590-192. Unfair Accident and Health Claims Settlement Practices.

 

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R590-192-9. Minimum Standards for Claim Benefit Determination and Settlement.

(1) All benefit determination time limits begin once the insurer receives a claim, without regard to whether all necessary information was filed with the original claim. If the insurer requires an extension due to the claimant's failure to submit necessary information, the time for making a decision is tolled from the date the notice is sent to the claimant through:

(a) the date that the claimant provides the necessary information; or

(b) 48 hours after the end of the period afforded the claimant to provide the specified additional information.

(2) Urgent Care Claims:

(a) In a case of urgent care, an insurer shall notify the claimant of the insurer's benefit decision, adverse or not, as soon as possible, taking into account the medical exigencies of the situation, but no later than[:

(i)] 72 hours after the receipt of the claim[ for health benefit plans, except for a grandfathered health benefit plan as defined in 45 CFR 147.140, starting with the plan year that begins on or after January 1, 2012; or

(ii) 72 hours after the receipt of the claim for all other accident and health coverage.]

(b)[(i) If]It is the insurer's duty to determine whether a claim is urgent based on the information provided by the claimant. If the claimant does not provide sufficient information for the plan to make a decision, the plan must notify the claimant as soon as possible, but not later than 24 hours after receipt of the claim, of the specific information that is required. The claimant shall be given reasonable time, but not less than 48 hours, to provide that information.

(ii) The insurer must notify the claimant of the insurer's decision as soon as possible but not later than 48 hours after the earlier of the plan's receipt of the requested information or the end of the time given to the claimant to provide the information.

(3) Concurrent Care Decision:

(a) Reduction or termination of concurrent care:

(i) Any reduction in the course of treatment is considered an adverse benefit determination.

(ii) The insurer must give the claimant notice, with sufficient time to appeal that adverse benefit determination and sufficient time to receive a decision of the appeal before any reduction or termination of care occurs.

(b) Extension of concurrent care:

(i) A claimant may request an extension of treatment beyond what has already been approved.

(ii) If the request for an extension is made at least 24 hours before the end of the approved treatment, the insurer must notify the claimant of the insurer's decision as soon as possible but no later than 24 hours after receipt of the claim.

(iii) If the request for extension does not involve urgent care, the insurer must notify the claimant of the insurer's benefit decision using the response times for a post-service claim.

(4) Pre-Service Benefit Determination:

(a) An insurer must notify the claimant of the insurer's benefit decision within 15 days of receipt of the request for care.

(b) If the insurer is unable to make a decision within that time due to circumstances beyond the insurer's control, such as late receipt of medical records, it must notify the claimant before expiration of the original 15 days that it intends to extend the time and then the insurer may take as long as 15 additional days to reach a decision.

(c) If the extension is due to failure of the claimant to submit necessary information, the extension notice of delay must give specific information about what the claimant has to provide and the claimant must be given at least 45 days to submit the requested information.

(d) once the pre-service claim determination has been made and the medical care rendered, the actual claim filed for payment will be processed according to the time requirements of a post-service claim.

(5) Post-Service Claims:

(a) An insurer must notify the claimant of the insurer's benefit decision within 30 days of receipt of the request for claim.

(b) If the insurer is unable to make a decision within that time due to circumstances beyond the insurer's control, such as late receipt of medical records, it must notify the claimant before expiration of the original 30 days that it intends to extend the time and then the insurer may take as long as 15 additional days to reach a decision.

(c) If the extension is due to failure of the claimant to submit necessary information, the extension notice of delay must give specific information about what the claimant has to provide and the claimant must be given at least 45 days to submit the requested information.

(6) A health benefit plan is required to provide continued coverage for an ongoing course of treatment pending the outcome of an internal appeal.

(7) Except for a grandfathered individual health benefit plan as defined in 45 CFR 147.140, an insurer offering an individual health benefit plan shall provide only one level of internal appeal before the final determination is made.

 

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KEY: insurance law

Date of Enactment or Last Substantive Amendment: 2011

Notice of Continuation: June 25, 2009

Authorizing, and Implemented or Interpreted Law: 31A-1-301; 31A-2-201; 31A-2-204; 31A-2-308; 31A-21-312; 31A-26-303