Insurance, Administration

Rule R590-203

Health Grievance Review Process

Change in Proposed Rule

DAR File No.: 35104
Filed: 10/14/2011 11:56:32 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

Language in Subsection R590-203-4(6)(a)(ii) is being reversed to language that was in the rule prior to 06/30/2011 regarding urgent care claims.

Summary of the rule or change:

A medical opinion in the case of an urgent care claim needs to be obtained from a physician rather than an attending provider who may not be a physician. (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 35. 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-2-203
• Section 31A-4-116
• Section 31A-22-629

Anticipated cost or savings to:

the state budget:

This change will have no impact on the department. It will not affect filings made to the office or revenues coming into the office.

local governments:

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

small businesses:

This change will require a physician, rather than attending provider, i.e., anyone other than a physician, to give a medical opinion to the insurer in the case of an urgent care claim. Those offices without a physician, or without an adequate number of physicians, may be required to hire where needed. This will differ from medical provider to medical provider.

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

This change could limit urgent care claims received by insurance companies, at least until medical providers acquire adequate staff.

Compliance costs for affected persons:

This change will require a physician, rather than attending provider, i.e., anyone other than a physician, to give a medical opinion to the insurer in the case of an urgent care claim. Those offices without a physician, or without an adequate number of physicians, may be required to hire where needed. This will differ from medical provider to medical provider. This change could limit urgent care claims received by insurance companies, at least until medical providers acquire adequate staff.

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

The impact of this change is unknown at this time. The impact will depend on the number of urgent care claims.

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.

R590-203. Health Grievance Review Process.

 

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R590-203-4. Definitions.

In addition to the definitions in Section 31A-1-301, the following definitions shall apply for the purposes of this rule:

(1)(a) "Adverse benefit determination" means the:

(i) denial of a benefit;

(ii) reduction of a benefit;

(iii) termination of a benefit; or

(iv) failure to provide or make payment, in whole or in part, for a benefit.

(b) "Adverse benefit determination" includes:

(i) denial, reduction, termination, or failure to provide or make payment that is based on a determination of an insured's eligibility to participate in a plan;

(ii) 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 a utilization review; and

(iii) failure to cover an item or service for which benefits are otherwise provided because it is determined to be:

(A) experimental;

(B) investigational; or

(C) not a medical necessity or appropriate.

(2) "Carrier" means any person or entity that provides health insurance or disability income insurance in this state including:

(a) an insurance company;

(b) a prepaid hospital or medical care plan;

(c) a health maintenance organization;

(d) a multiple employer welfare arrangement; and

(e) any other person or entity providing a health insurance or disability income insurance plan under Title 31A.

(3) "Consumer Representative" may be an employee of the carrier who is a consumer of a health insurance or a disability income policy, as long as the employee is not:

(a) the individual who made the adverse determination; or

(b) a subordinate to the individual who made the adverse determination.

(4) "Medical Necessity" means:

(a) health care services or products that a prudent health care professional would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is:

(i) in accordance with generally accepted standards of medical practice in the United States;

(ii) clinically appropriate in terms of type, frequency, extent, site, and duration;

(iii) not primarily for the convenience of the patient, physician, or other health care provider; and

(iv) covered under the contract; and

(b) that when a medical question-of-fact exists medical necessity shall include the most appropriate available supply or level of service for the individual in question, considering potential benefits and harms to the individual, and known to be effective.

(i) For interventions not yet in widespread use, the effectiveness shall be based on scientific evidence.

(ii) For established interventions, the effectiveness shall be based on:

(A) scientific evidence;

(B) professional standards; and

(C) expert opinion.

(5)(a) "Scientific evidence" means:

(i) scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff; or

(ii) findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes.

(b) Scientific evidence shall not include published peer-reviewed literature sponsored to a significant extent by a pharmaceutical manufacturing company or medical device manufacturer or a single study without other supportable studies.

(6)(a) "Urgent care claim" means a request for a health care service or course of treatment with respect to which the time periods for making non-urgent care request determination:

(i) could seriously jeopardize the life or health of the insured or the ability of the insured to regain maximum function; or

(ii) in the opinion of [the insured's attending provider]a physician with knowledge of the insured's medical condition, would subject the insured to severe pain that cannot be adequately managed without the health care service or treatment that is the subject of the request.

(b)(i) Except as provided in Subsection (6)(a)(ii), in determining whether a request is to be treated as an urgent care request, an individual acting on behalf of the carrier shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

(ii) Any request that a physician with knowledge of the insured's medical condition determines is an urgent care request within the meaning of Subsection (6)(a) shall be treated as an urgent care claim.

 

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KEY: insurance

Date of Enactment or Last Substantive Amendment: 2011

Notice of Continuation: April 17, 2007

Authorizing, and Implemented or Interpreted Law: 31A-2-201; 31A-2-203; 31A-4-116; 31A-22-629