58-17I-6. Grievance procedures--Filing--Certificate of compliance--Contact information.
Except as specified in this chapter, each health carrier shall use written procedures for receiving and resolving grievances from covered persons, as provided in §§58-17I-7 to 58-17I-11, inclusive. If a health carrier fails to strictly adhere to the requirements of §§58-17I-7 to 58-17I-10, inclusive, or §§58-17I-12 to 58-17I-15, inclusive, with respect to receiving and resolving grievances involving an adverse determination, the covered person shall be deemed to have exhausted the provisions of this chapter, and may take action regardless of whether the health carrier asserts that the carrier substantially complied with the requirements of §§58-17I-7 to 58-17I-10, inclusive, or §§58-17I-12 to 58-17I-15, inclusive, or that any error the carrier committed was de minimus.
A covered person may file a request for external review in accordance with rules promulgated by the director. In addition 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.
A health carrier shall file with the director a copy of the procedures required under this section, including all forms used to process requests made pursuant to §§58-17I-7 to 58-17I-11, inclusive. Any subsequent material modifications to the documents also shall be filed. The director may disapprove a filing received in accordance with this section that fails to comply with this chapter, or applicable rules. In addition, a health carrier shall file annually with the director, as part of its annual report required by §§58-17I-4 and 58-17I-5, a certificate of compliance stating that the health carrier has established and maintains, for each of its health benefit plans, grievance procedures that fully comply with the provisions of this chapter. A description of the grievance procedures required under this section shall be set forth in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage provided to covered persons. The grievance procedure documents shall include a statement of a covered person's right to contact the Division of Insurance for assistance at any time. The statement shall include the telephone number and address of the Division of Insurance. (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, §78.