Section R590-285-24 - Appealing an Insurer's Determination That the Benefit Trigger is Not Met(1) For purposes of this section, "authorized representative" is authorized to act as the covered person's personal representative within the meaning of 45 CFR 164.502(g) promulgated by the Secretary under the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act and means the following: (a) a person to whom a covered person has given express written consent to represent the covered person in an external review;(b) a person authorized by law to provide substituted consent for a covered person; or(c) a family member of the covered person or the covered person's treating health care professional only when the covered person is unable to provide consent.(2) If an insurer determines that the benefit trigger of a limited long-term care insurance policy has not been met, it shall provide a clear, written notice to the insured and the insured's authorized representative, if applicable, of all of the following: (a) the reason that the insurer determined that the insured's benefit trigger has not been met;(b) the insured's right to internal appeal in accordance with Subsection R590-285-24(3), and the right to submit new or additional information relating to the benefit trigger denial with the appeal request; and(c) the insured's right, after exhaustion of the insurer's internal appeal process, to have the benefit trigger determination reviewed under the independent review process in accordance with Section R590-285-25.(3) Internal Appeal. (a) The insured or the insured's authorized representative may appeal the insurer's adverse benefit trigger determination by sending a written request to the insurer, along with any additional supporting information, within 180 days after the insured and the insured's authorized representative, if applicable, receives the insurer's benefit determination notice.(b) The internal appeal shall be considered by an individual or group of individuals designated by the insurer, provided that the individual or individuals making the internal appeal decision may not be the same individual or individuals who made the initial benefit determination.(c) The internal appeal shall be completed, and written notice of the internal appeal decision shall be sent to the insured and the insured's authorized representative, if applicable, within 30 calendar days of the insurer's receipt of all necessary information upon which a final determination can be made.(d) If the insurer's original determination is upheld after the internal appeal process has been exhausted and new or additional information has not been provided to the insurer, the insurer shall provide a written description of the insured's right to request an independent review of the benefit determination as described in Section R590-285-25 to the insured and the insured's authorized representative, if applicable.(e) As part of the written description of the insured's right to request an independent review, an insurer shall include the following, or substantially equivalent, language: "We have determined that the benefit eligibility criteria ("benefit trigger") of your (policy) (certificate) has not been met. You may have the right to an independent review of our decision conducted by long-term care professionals who are not associated with us. Please send a written request for independent review to us at (address). You must inform us, in writing, of your election to have this decision reviewed within 180 days of receipt of this letter. We will choose an independent review organization for you and refer the request for independent review to it."(f) If the insurer does not believe the benefit trigger decision is eligible for independent review, the insurer shall inform the insured and the insured's authorized representative, if applicable, in writing and include in the notice the reasons for its determination of independent review ineligibility.(g) The appeal process is not deemed to be a "new service or provider" as referenced in Section R590-285-20 and therefore does not trigger the notice requirements of that section.Utah Admin. Code R590-285-24
Adopted by Utah State Bulletin Number 2021-05, effective 2/23/2021