58-17H-19. Determinations to be issued in timely manner--Process to ensure consistency.
A health carrier shall issue utilization review and benefit determinations in a timely manner pursuant to the requirements of §§58-17H-27 to 58-17H-32, inclusive, and §§58-17H-40 to 58-17H-48, inclusive. A health carrier shall have a process to ensure that utilization reviewers apply clinical review criteria in conducting utilization review consistently.
If a health carrier fails to strictly adhere to the requirements of §§58-17H-27 to 58-17H-32, inclusive, and §§58-17H-40 to 58-17H-48, inclusive, with respect to making utilization review and benefit determinations of a benefit request or claim, the covered person shall be deemed to have exhausted the provisions of chapters 58-17G and 58-17H, and may take action regardless of whether the health carrier asserts that the carrier substantially complied with the requirements of §§58-17H-27 to 58-17H-32, inclusive, and §§58-17H-40 to 58-17H-48, inclusive, as applicable, or that any error it committed was de minimus.
Any covered person may file a request for external review in accordance with rules promulgated by the director. In addition to the external review rights a covered person is entitled to pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal claims and appeals process that would yield a decision on the merits of the claim. (SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.")
Source: SL 2011, ch 219, §44.