3 AAC 28 — Life, Health, Variable, and Related Insurance (Article 1 to 13)

(a) A health care insurer shall establish and maintain written procedures for (1) receiving a benefit request from a covered person or the covered person's authorized representative; (2) making a standard utilization review and benefit determination; and (3) notifying a covered p…

(a) A health care insurer shall establish and maintain written procedures for (1) receiving a benefit request from a covered person or the covered person's authorized representative; (2) making an expedited utilization review and benefit determination with respect to(A) an urgent…

(a) A health care insurer shall follow the provisions of this section when conducting a utilization review or making a benefit determination for emergency services. (b) A health care insurer shall cover emergency services to screen and stabilize a covered person (1) without the n…

A health care insurer shall annually certify in writing to the director that the utilization review program of the health care insurer or the health care insurer's designee complies with all applicable state and federal laws that establish confidentiality and reporting requiremen…

(a) A health care insurer shall set out in, or attach to, a policy, certificate of coverage, membership booklet, or other evidence of coverage provided to a covered person by a health care insurer a clear and comprehensive description of the health care insurer's utilization revi…

Except as otherwise provided, 3 AAC 28.930- 3 AAC 28.938 apply to a health care insurer transacting health care insurance in this state. Notes 3 AAC 28.930 Eff. 3/15/2018,Register 225, April 2018 Authority:AS 21.06.090 AS 21.07.005 State regulations are updated quarterly; we curr…

(a) A health care insurer shall maintain a written calendar year register, in a manner that is reasonably clear and accessible to the director, to document (1) each grievance received; (2) a general description of the reason for the grievance; (3) the date the grievance was recei…

(a) Except as specified under 3 AAC 28.938, a health care insurer shall use written procedures for receiving and resolving a grievance under 3 AAC 28.930 - 3 AAC 28.938. (b) A covered person will be considered to have exhausted the provisions of 3 AAC 28.930 - 3 AAC 28.938 if a h…

(a) A covered person or the covered person's authorized representative may file a grievance with a health care insurer requesting a review of an adverse determination, The covered person or the covered person's authorized representative shall file the request not later than 180 d…

(a) A health care insurer shall establish written procedures for the expedited review of an urgent care request of a grievance involving an adverse determination. The procedures must allow a covered person or the covered person's authorized representative to request an expedited …

(a) Except under (b) of this section, 3 AAC 28.950-3 AAC 28.982 apply to a health care insurer that transacts health care insurance in this state. (b) The provisions of 3 AAC 28.950 - 3 AAC 28.982 do not apply to (1) a policy or certificate that provides coverage only for a speci…

(a) A health care insurer shall notify a covered person or the covered person's authorized representative in writing of the covered person's right to request an external review under 3 AAC 28.958 - 3 AAC 28.962. A health care insurer shall provide the notice of the right to reque…

(a) A covered person or the covered person's authorized representative may make a request to the director for an external review of an adverse determination or a final adverse determination. Except for a request for an expedited external review, a covered person or the covered pe…

(a) Except as otherwise provided under this section, before making a request for an external review, a covered person or the covered person's authorized representative must exhaust a health care insurer's internal grievance process under 3 AAC 28.930 - 3 AAC 28.938. (b) A covered…

(a) A covered person or a covered person's authorized representative may file a request with the director for a standard external review of a health care insurer's adverse determination or final adverse determination not later than 180 days after (1) receipt of a notice of an adv…

(a) Except under (k) of this section, a covered person or the covered person's authorized representative may make an oral or written request to the director for an expedited external review of a health care insurer's adverse determination or final adverse determination when the c…

(a) A covered person or the covered person's authorized representative may file a request with the director for an external review not later than 180 days after receipt of a health care insurer's notice of adverse determination or final adverse determination that involves a denia…

Not later than 24 hours after receipt of an assignment to conduct an external review under 3 AAC 28.958(i)(1), 3 AAC 28.960(e)(1), or 3 AAC 28.962(f)(1), an independent review organization shall (1) make a determination of the independent review organization's ability to perform …

(a) An external review decision is binding on a health care insurer except to the extent the health care insurer has other remedies available under applicable state law. (b) An external review decision is binding on the covered person except to the extent the covered person has o…

(a) An initial biennial independent review Organization registration period includes the rest of the calendar year in which the registration is issued and all of the following calendar year. (b) If the director issues an initial biennial independent review organization registrati…

(a) The director may assign an independent review organization to conduct an external review in this state if the independent review organization (1) has an approved registration application on file with the director; (2) has paid the independent review organization biennial regi…

(a) To determine compliance with 3 AAC 28.950 - 3 AAC 28.989, the director may examine the affairs, transactions, accounts, records, and documents of an independent review organization. The director, after a hearing, may suspend or revoke an independent review organization regist…

(a) An independent review organization is eligible to conduct external reviews under 3 AAC 28.950 - 3 AAC 28.982, if the independent review organization has and maintains written policies and procedures that govern all aspects of the standard external review process and the exped…

An independent review organization, a clinical reviewer working on behalf of an independent review organization, or an employee, agent, or contractor of an independent review organization may not be liable in damages to a person for an opinion rendered, or act or omission perform…

(a) An independent review organization assigned to conduct an external review shall maintain written records, in the aggregate by state and by health care insurer, of requests for external review for which the independent review organization conducted external reviews during a ca…

A health care insurer against which a request for a standard external] review or an expedited external review is filed shall pay the cost of the independent review organization to conduct the external review. Notes 3 AAC 28.980 Eff. 3/15/2018,Register 225, April 2018 Authority:AS…

A health care insurer shall set out in, or attach to, a policy, certificate of coverage, membership booklet, or other evidence of coverage provided to a covered person a description of the external review procedures described under 3 AAC 28.950"3 AAC 28.982. The description must …

In 3 AAC 28.900 - 3 AAC 28.989, unless the context requires otherwise, (1) "adverse determination" includes a rescission of coverage determination and means (A) a determination by a health care insurer or the health care insurer's designee utilization review organization that (i)…