Utah Code 31A-22-629. Adverse benefit determination review process
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(1) As used in this section:
Terms Used In Utah Code 31A-22-629
- Administrator: means the same as that term is defined in Subsection (187). See Utah Code 31A-1-301
- Application: means a document:(10)(a)(10)(a)(i) completed by an applicant to provide information about the risk to be insured; and(10)(a)(ii) that contains information that is used by the insurer to evaluate risk and decide whether to:(10)(a)(ii)(A) insure the risk under:(10)(a)(ii)(A)(I) the coverage as originally offered; or(10)(a)(ii)(A)(II) a modification of the coverage as originally offered; or(10)(a)(ii)(B) decline to insure the risk; or(10)(b) used by the insurer to gather information from the applicant before issuance of an annuity contract. See Utah Code 31A-1-301
- Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
- Contract: A legal written agreement that becomes binding when signed.
- Director: means a member of the board of directors of a corporation. See Utah Code 31A-1-301
- Disability: means a physiological or psychological condition that partially or totally limits an individual's ability to:
(51)(a) perform the duties of:(51)(a)(i) that individual's occupation; or(51)(a)(ii) an occupation for which the individual is reasonably suited by education, training, or experience; or(51)(b) perform two or more of the following basic activities of daily living:(51)(b)(i) eating;(51)(b)(ii) toileting;(51)(b)(iii) transferring;(51)(b)(iv) bathing; or(51)(b)(v) dressing. See Utah Code 31A-1-301- Employee: means :
(57)(a) an individual employed by an employer; or(57)(b) an individual who meets the requirements of Subsection (55)(b). See Utah Code 31A-1-301- Enrollee: includes an insured. See Utah Code 31A-1-301
- Fiduciary: A trustee, executor, or administrator.
- Health care: means any of the following intended for use in the diagnosis, treatment, mitigation, or prevention of a human ailment or impairment:
(83)(a) a professional service;(83)(b) a personal service;(83)(c) a facility;(83)(d) equipment;(83)(e) a device;(83)(f) supplies; or(83)(g) medicine. See Utah Code 31A-1-301- Health care provider: means the same as that term is defined in Section
78B-3-403 . See Utah Code 31A-1-301- health insurance: means insurance providing:
(84)(a)(i) a health care benefit; or(84)(a)(ii) payment of an incurred health care expense. See Utah Code 31A-1-301- Insurance: includes :
(96)(b)(i) a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;(96)(b)(ii) a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and(96)(b)(iii) a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301- Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
(103)(a)(i) a policyholder;(103)(a)(ii) a subscriber;(103)(a)(iii) a member; and(103)(a)(iv) a beneficiary. See Utah Code 31A-1-301- Person: includes :
(146)(a) an individual;(146)(b) a partnership;(146)(c) a corporation;(146)(d) an incorporated or unincorporated association;(146)(e) a joint stock company;(146)(f) a trust;(146)(g) a limited liability company;(146)(h) a reciprocal;(146)(i) a syndicate; or(146)(j) another similar entity or combination of entities acting in concert. See Utah Code 31A-1-301- Policy: includes a service contract issued by:
(150)(b)(i) a motor club under Chapter 11, Motor Clubs;(150)(b)(ii) a service contract provided under Chapter 6a, Service Contracts; and(150)(b)(iii) a corporation licensed under:(150)(b)(iii)(A) Chapter 7, Nonprofit Health Service Insurance Corporations; or(150)(b)(iii)(B) Chapter 8, Health Maintenance Organizations and Limited Health Plans. See Utah Code 31A-1-301- Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5
(1)(a)(1)(a)(i) “Adverse benefit determination” means the:(1)(a)(i)(A) denial of a benefit;(1)(a)(i)(B) reduction of a benefit;(1)(a)(i)(C) termination of a benefit; or(1)(a)(i)(D) failure to provide or make payment, in whole or in part, for a benefit.(1)(a)(ii) “Adverse benefit determination” includes:(1)(a)(ii)(A) denial, reduction, termination, or failure to provide or make payment that is based on a determination of an insured‘s or a beneficiary‘s eligibility to participate in a plan;(1)(a)(ii)(B) 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; or(1)(a)(ii)(C) failure to cover an item or service for which benefits are otherwise provided because it is determined to be:(1)(a)(ii)(C)(I) experimental;(1)(a)(ii)(C)(II) investigational; or(1)(a)(ii)(C)(III) not medically necessary or appropriate.(1)(b) “Independent review” means a process that:(1)(b)(i) is a voluntary option for the resolution of an adverse benefit determination;(1)(b)(ii) is conducted at the discretion of the claimant;(1)(b)(iii) is conducted by an independent review organization designated by the commissioner;(1)(b)(iv) renders an independent and impartial decision on an adverse benefit determination submitted by an insured; and(1)(b)(v) may not require the insured to pay a fee for requesting the independent review.(1)(c) “Independent review organization” means a person, subject to Subsection (6), who conducts an independent external review of adverse determinations.(1)(d) “Insured” is as defined in Section 31A-1-301 and includes a person who is authorized to act on the insured’s behalf.(1)(e) “Insurer” is as defined in Section 31A-1-301 and includes:(1)(e)(i) a health maintenance organization; and(1)(e)(ii) a third party administrator that offers, sells, manages, or administers a health insurance policy or health maintenance organization contract that is subject to this title.(1)(f) “Internal review” means the process an insurer uses to review an insured’s adverse benefit determination before the adverse benefit determination is submitted for independent review.(2) This section applies generally to health insurance policies, health maintenance organization contracts, and income replacement or disability income policies.(3)(3)(a) An insured may submit an adverse benefit determination to the insurer.(3)(b) The insurer shall conduct an internal review of the insured’s adverse benefit determination.(3)(c) An insured who disagrees with the results of an internal review may submit the adverse benefit determination for an independent review if the adverse benefit determination involves:(3)(c)(i) payment of a claim regarding medical necessity; or(3)(c)(ii) denial of a claim regarding medical necessity.(4) The commissioner shall adopt rules that establish minimum standards for:(4)(a) internal reviews;(4)(b) independent reviews to ensure independence and impartiality;(4)(c) the types of adverse benefit determinations that may be submitted to an independent review; and(4)(d) the timing of the review process, including an expedited review when medically necessary.(5) Nothing in this section may be construed as:(5)(a) expanding, extending, or modifying the terms of a policy or contract with respect to benefits or coverage;(5)(b) permitting an insurer to charge an insured for the internal review of an adverse benefit determination;(5)(c) restricting the use of arbitration in connection with or subsequent to an independent review; or(5)(d) altering the legal rights of any party to seek court or other redress in connection with:(5)(d)(i) an adverse decision resulting from an independent review, except that if the insurer is the party seeking legal redress, the insurer shall pay for the reasonable attorney fees of the insured related to the action and court costs; or(5)(d)(ii) an adverse benefit determination or other claim that is not eligible for submission to independent review.(6)(6)(a) An independent review organization in relation to the insurer may not be:(6)(a)(i) the insurer;(6)(a)(ii) the health plan;(6)(a)(iii) the health plan’s fiduciary;(6)(a)(iv) the employer; or(6)(a)(v) an employee or agent of any one listed in Subsections (6)(a)(i) through (iv).(6)(b) An independent review organization may not have a material professional, familial, or financial conflict of interest with:(6)(b)(i) the health plan;(6)(b)(ii) an officer, director, or management employee of the health plan;(6)(b)(iii) the enrollee;(6)(b)(iv) the enrollee’s health care provider;(6)(b)(v) the health care provider‘s medical group or independent practice association;(6)(b)(vi) a health care facility where service would be provided; or(6)(b)(vii) the developer or manufacturer of the service that would be provided.