Section R590-285-25 - Independent Review of Benefit Trigger Determination(1) Request. The insured or the insured's authorized representative may request an independent review of the insurer's benefit trigger determination after the internal appeal process outlined in Subsection R590-285-24(3) has been exhausted. A written request for independent review may be made by the insured or the insured's authorized representative to the insurer within 180 days after the insurer's written notice of the final internal appeal decision is received by the insured and the insured's authorized representative, if applicable. (2) Cost. The cost of the independent review shall be borne by the insurer.(3) Independent Review Process.(a) Within five business days of receiving a written request for independent review, the insurer shall refer the request to the independent review organization. The insurer shall choose an independent review organization approved by the commissioner. The insurer shall vary its selection of authorized independent review organizations on a rotating basis.(b) The insurer shall refer the request for independent review of a benefit trigger determination to an independent review organization, subject to the following:(i) the independent review organization shall be on a list of approved independent review organizations that satisfy the requirements of a qualified long-term care insurance independent review organization contained in this section;(ii) the independent review organization may not have any conflicts of interest with the insured, the insured's authorized representative, if applicable, or the insurer; and(iii) such review shall be limited to the information or documentation provided to and considered by the insurer in making its determination, including any information or documentation considered as part of the internal appeal process.(c) If the insured or the insured's authorized representative has new or additional information not previously provided to the insurer, whether submitted to the insurer or the independent review organization, such information shall first be considered in the internal review process, as set forth in Subsection R590-285-24(3). (i) While this information is being reviewed by the insurer, the independent review organization shall suspend its review and the time period for review is suspended until the insurer completes its review.(ii) The insurer shall complete its review of the information and provide written notice of the results of the review to the insured and the insured's authorized representative, if applicable, and the independent review organization within five business days of the insurer's receipt of such new or additional information.(iii)(A) If the insurer maintains its denial after such review, the independent review organization shall continue its review, and render its decision within the time period specified in Subsection R590-285-25(3)(i).(B) If the insurer overturns its decision following its review, the independent review request shall be considered withdrawn.(d) The insurer shall acknowledge in writing to the insured and the insured's authorized representative, if applicable, and the commissioner that the request for independent review has been received, accepted, and forwarded to an independent review organization for review. Such notice will include the name and address of the independent review organization.(e) Within five business days of receipt of the request for independent review, the independent review organization assigned shall notify the insured and the insured's authorized representative, if applicable, and the insurer, that it has accepted the independent review request and identify the type of licensed health care professional assigned to the review. The assigned independent review organization shall include in the notice a statement that the insured or the insured's authorized representative may submit in writing to the independent review organization, within seven days following the date of receipt of the notice, additional information and supporting documentation that the independent review organization should consider when conducting its review. (f) The independent review organization shall review all of the information and documents that are provided to the independent review organization. The independent review organization shall provide copies of any documentation or information provided by the insured or the insured's authorized representative to the insurer for its review, if it is not part of the information or documentation submitted by the insurer to the independent review organization. The insurer shall review the information and provide its analysis of the new information in accordance with Subsection R590-285-25(3)(h).(g) The insured or the insured's authorized representative may submit, at any time, new or additional information not previously provided to the insurer but that is pertinent to the benefit trigger denial. The insurer shall consider such information and affirm or overturn its benefit trigger determination. If the insurer affirms its benefit trigger determination, the insurer shall promptly provide such new or additional information to the independent review organization for its review, along with the insurer's analysis of such information.(h) If the insurer overturns its benefit trigger determination:(i) the insurer shall provide notice to the independent review organization, the insured, and the insured's authorized representative, if applicable, of its decision; and(ii) the independent review process shall immediately cease.(i) The independent review organization shall provide the insured and the insured's authorized representative, if applicable, and the insurer written notice of its decision, within 30 days from receipt of the referral. If the independent review organization overturns the insurer's decision, it shall:(i) establish the precise date within the specific period of time under review that the benefit trigger was deemed to have been met; and(ii) specify the specific period of time under review for which the insurer declined eligibility, but during which the independent review organization deemed the benefit trigger to have been met.(j) The decision of the independent review organization with respect to whether the insured met the benefit trigger will be final and binding on the insurer.(k) The independent review organization's determination shall be used solely to establish liability for benefit trigger decisions, and is intended to be admissible in any proceeding only to the extent it establishes the eligibility of benefits payable.(l) Nothing in this section shall restrict the insured's right to submit a new request for benefit trigger determination after the independent review decision, should the independent review organization uphold the insurer's decision.(m)(i) The commissioner shall utilize the criteria set forth in Appendix F, Guidelines for Long-Term Care Independent Review Entities, in approving entities to review long-term care insurance benefit trigger decisions. (ii) The commissioner shall accept another state's certification of an independent review organization, provided such state requires the independent review organization to meet substantially similar qualifications as those contained in Appendix F.(n) The commissioner shall maintain and periodically update a list of approved independent review organizations.(4) Certification of Long-Term Care Insurance Independent Review Organizations. The commissioner shall certify or approve a qualified long-term care insurance independent review organization, provided the independent review organization demonstrates to the satisfaction of the commissioner that it is unbiased and meets the following qualifications:(a) have on staff, or contract with, a qualified and licensed health care professional in an appropriate field for determining an insured's functional or cognitive impairment such as physical therapy, occupational therapy, neurology, physical medicine, and rehabilitation, to conduct the review;(b) neither it nor any of its licensed health care professionals may, in any manner, be related to or affiliated with an entity that previously provided medical care to the insured;(c) utilize a licensed health care professional who is not an employee of the insurer or related in any manner to the insured;(d) neither it nor its licensed health care professional who conducts the reviews may receive compensation of any type that is dependent on the outcome of the review;(e) be approved by the commissioner to conduct such reviews if the state requires such approvals or certifications;(f) provide a description of the fees to be charged by it for independent reviews of a limited long-term care insurance benefit trigger decision. Such fees shall be reasonable and customary for the type of limited long-term care insurance benefit trigger decision under review; and(g) provide the name of the medical director or health care professional responsible for the supervision and oversight of the independent review procedure.(5) Maintenance of Records and Reporting Obligations by Independent Review Organizations. Each certified independent review organization shall comply with the following: (a) maintain written documentation establishing the date it receives a request for independent review, the date each review is conducted, the resolution, the date such resolution was communicated to the insurer and the insured, the name and professional status of the reviewer conducting such review in an easily accessible and retrievable format for the year in which it received the information, plus three calendar years;(b) be able to document measures taken to appropriately safeguard the confidentiality of such records and prevent unauthorized use and disclosures in accordance with applicable federal and state law;(c) report annually to the commissioner, by June 1 for the previous calendar year, in the aggregate and for each limited long-term care insurer all of the following: (i) the total number of requests received for independent review of limited long-term care benefit trigger decisions;(ii) the total number of reviews conducted and the resolution of such reviews;(iii) the number of reviews withdrawn prior to review; and(iv) the percentage of reviews conducted within the prescribed timeframe set forth in Subsection R590-285-25(3)(i); and(d) report immediately to the commissioner any change in its status which would cause it to cease meeting any of the qualifications required of an independent review organization performing independent reviews of limited long-term care benefit trigger decisions.(6) Additional Rights. Nothing contained in this section shall limit the ability of an insurer to assert any rights an insurer may have under the policy related to:(a) an insured's misrepresentation;(b) changes in the insured's benefit eligibility; and(c) terms, conditions, and exclusions of the policy, other than failure to meet the benefit trigger.Utah Admin. Code R590-285-25
Adopted by Utah State Bulletin Number 2021-05, effective 2/23/2021