Alaska Administrative Code

In this chapter, (1) "the 1983 Table 'a'" means the mortality table developed by the Society of Actuaries Committee to Recommend a New Mortality Basis for Individual Annuity Valuation, and adopted as a recognized mortality table for annuities in June 1982 by the National Associat…

(a)3 AAC 28.700 - 3 AAC 28.725 apply to all insurers transacting health insurance in this state for claims that are paid on an expense-incurred basis. (b)3 AAC 28.700 - 3 AAC 28.725 do not apply to claims for vision care or drugs, or to benefits paid on other than an expense-incu…

(a) An insurer shall accept a properly completed claim submitted on the applicable uniform form set out in Uniform Claim Forms for Health Insurance, dated June 23, 1995 and hereby adopted by reference. A properly completed claim includes (1) completion of a uniform claim form wit…

For purposes of 3 AAC 28.700 - 3 AAC 28.725, "health insurance" means an individual or group contract or other plan providing coverage for health care services that is issued by an insurer licensed to transact the business of health insurance; a health maintenance organization un…

(a) A health care insurer that offers, issues for delivery, delivers, or renews a health care insurance plan that provides coverage for prescription drugs or devices and that issues, uses, requires, or reissues a card for prescription claims processing shall issue to a covered in…

A health care insurer must comply with 3 AAC 28.740 for new policies issued on or after 12 months from the effective date of 3 AAC 28.740 and for renewal policies on the first renewal date after 12 months from the effective date of 3 AAC 28.740. Notes 3 AAC 28.745 Eff. 9/15/2004,…

The purpose of 3 AAC 28.800 - 3 AAC 28.849 is to protect the public from false, misleading, or deceptive illustrations of life insurance policies by (1) providing formats for life insurance policy illustrations; (2) specifying the disclosures that are required for life insurance …

(a)3 AAC 28.800 - 3 AAC 28.849 apply to all group and individual life insurance policies and certificates except (1) variable life insurance; (2) individual and group annuity contracts; (3) credit life insurance under AS 21.57; and (4) individual and group life insurance policies…

(a) When a policy form subject to 3 AAC 28.800 - 3 AAC 28.849 is filed under AS 21.42.120, the insurer marketing that policy form shall notify the director in writing whether the policy form will be marketed with or without an illustration. For a policy form subject to 3 AAC 28.8…

(a) Failure to comply with 3 AAC 28.800 - 3 AAC 28.849 is a violation of AS 21.36.020 and 21.36.030. (b) An illustration used in the sale of a life insurance policy must satisfy the requirements of 3 AAC 28.800 - 3 AAC 28.849, be clearly labeled "life insurance illustration," and…

(a) Format. A basic illustration must conform with the following requirements: (1) the terms used in an illustration must be consistent with the terms used in the policy that is being illustrated; (2) an illustration must be labeled with the date on which it was prepared; (3) eac…

(a) A supplemental illustration may be provided if: (1) it is appended to, accompanied by, or preceded by a basic illustration that complies with 3 AAC 28.800 - 3 AAC 28.849; (2) the non-guaranteed elements shown in the supplemental illustration are not more favorable to the poli…

(a) If a basic illustration is used in the solicitation of a life insurance policy that is applied for as illustrated, the person soliciting the policy must provide a copy of that illustration, signed as required under 3 AAC 28.820, to the applicant at the time of application and…

(a) If a policy is designated as one for which an illustration will be used, the insurer shall provide each policy owner with an annual report on the status of the policy that contains at least the following information: (1) for a universal life policy, the report must include (A…

(a) The board of directors of an insurer shall appoint one or more illustration actuaries. The illustration actuary or actuaries shall annually certify that the disciplined current scale used in each illustration in current use, as well as those used since the prior certification…

(a) In determining the disciplined current scale, an insurer may rely on the standards established by the Actuarial Standards Board if the standards (1) conform with the requirements of 3 AAC 28.800 - 3 AAC 28.849; (2) limit a disciplined current scale to reflect only actions tha…

For the purposes of 3 AAC 28.800 - 3 AAC 28.849, (1) "Actuarial Standards Board" means the board established by the American Academy of Actuaries to develop and adopt standards of actuarial practice; (2) "basic illustration" means a presentation or depiction used in the sale of a…

3 AAC 28.900 - 3 AAC 28.918 apply to (1) a health care insurer that (A) transacts health care insurance in this state; and (B) provides or performs utilization review services; (2) a designee of the health care insurer under (1) of this section, including a utilization review org…

A health care insurer shall (1) monitor all utilization review activities carried out by, or on behalf of, the health care insurer; (2) ensure that the requirements of 3 AAC 28.900 - 3 AAC 28.918 are met; and (3) ensure that appropriate personnel have operational responsibility f…

If a health care insurer contracts to have a utilization review organization or other entity perform the utilization review functions required under 3 AAC 28.900 - 3 AAC 28.918, the director will (1) hold the health care insurer responsible for monitoring the activities of the ut…

(a) A health care insurer that requires utilization review of a benefit request under a health care insurance policy shall develop and implement a written utilization review program that describes, at a minimum, the following utilization review activities: (1) filing of a benefit…

(a) A utilization review program must use documented clinical review criteria that are (1) based on sound clinical evidence; and (2) evaluated periodically by a health care insurer's organizational mechanism specified under 3 AAC 28.906(b)(6) to ensure the program's effectiveness…

(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…