Title 20 — Insurance

A. The director shall annually report the following information to the president of the senate and the speaker of the house of representatives: 1. The number of risk retention groups licensed in this state since August 6, 2016. 2. Any regulatory action taken by the director again…

A. In this chapter, unless the context otherwise requires: 1. "Adverse determination": (a) Means a utilization review determination by the utilization review agent that a requested service or claim for service or a denial, reduction or termination of a service, in whole or in par…

A. A utilization review agent shall not conduct utilization review in this state unless the utilization review agent meets or is exempt from this article. B. A person is exempt from sections 20-2504, 20-2505, 20-2506, 20-2507 and 20-2508 and section 20-2509, subsection A if the p…

A. The utilization review standards established in this chapter apply to prospective, concurrent and retrospective utilization review for: 1. Inpatient admissions to hospitals and other inpatient facilities. 2. Outpatient admissions to surgical facilities. 3. Outpatient surgical …

A. The director shall issue a certificate to a utilization review agent that meets all of the requirements of this chapter and all applicable rules. A utilization review agent shall submit a signed and notarized application on a form prescribed by the director. B. A certificate i…

A utilization review agent applying for a certificate shall submit the following information to the department: 1. A signed and notarized application on a form prescribed by the director. 2. A utilization review plan that includes a summary description of review guidelines, proto…

A. The director shall examine the affairs, transactions, accounts and records of each utilization review agent before issuing an initial certificate and as often as the director deems it necessary in order to determine if a utilization review agent is in compliance with this chap…

A. A certificate expires on the third anniversary of its effective date unless the certificate is renewed for a three year term as provided in this section. B. A certificate holder may renew an unexpired certificate for an additional three year term if the certificate holder meet…

A. The director shall deny a certificate if the director finds that the utilization review agent does not: 1. Have an allopathic or osteopathic physician available to supervise utilization review activities of any medical, surgical or health care services except that: (a) A denta…

A. A utilization review agent shall file with the director written procedures for assuring that patient information it obtains during the process of utilization review is maintained as confidential in accordance with applicable federal and state laws, is used solely for the purpo…

A. A health care insurer that proposes to provide coverage of inpatient hospital and medical benefits, outpatient surgical benefits or any medical, surgical or health care service for residents of this state with utilization review of those benefits shall meet at least one of the…

If the director believes that a utilization review agent is violating or is about to violate section 20-2502, the director may order the agent to cease and desist. The director through the attorney general may file a complaint in the superior court in the county in which the agen…

For the purposes of this article: 1. "Member" means a person who is covered under a health care plan provided by a health care insurer or that person's treating provider, parent, legal guardian, surrogate who is authorized to make health care decisions for that person by a power …

A. Notwithstanding article 1 of this chapter and subject to subsection B of this section, this article applies to all utilization review decisions made by utilization review agents and health care insurers operating in this state. B. Each utilization review agent and each health …

A. Each utilization review agent shall: 1. Adopt a written utilization review plan with standards and criteria that apply to all utilization review determinations and that are objective, clinically valid and compatible with established principles of health care. 2. Establish the …

A. No minimum dollar amount may be imposed on any claim that is the subject of an adverse determination for a member to, and any member who receives an adverse determination may, pursue the applicable review process prescribed in this article. Except as provided in sections 20-25…

A. Except for a denial of a claim for service or a rescission of coverage, any member who receives an adverse determination may pursue an expedited medical review of that denial if the member's treating provider certifies in writing and provides supporting documentation to the ut…

A. Any member who receives an adverse determination and who does not qualify for an expedited medical review pursuant to section 20-2534 may request, either orally or in writing, an initial appeal of that denial by notifying the person described in section 20-2533, subsection H, …

A. For a group health plan, or a grandfathered individual plan, if a health care insurer elects to include as part of its internal review levels a voluntary internal appeal level after any applicable initial appeal pursuant to section 20-2535 and the utilization review agent deni…

(Conditionally Rpld.) A. If the utilization review agent denies the member's request for a covered service or claim for a covered service at all applicable internal levels of review or if the member has exhausted the health care insurer's internal levels of review pursuant to sec…

A. Pursuant to title 41, chapter 23, the director shall procure as many independent review organizations as necessary and practicable to perform the independent medical reviews described in section 20-2537. B. Through the procurement process the director shall ensure that any pro…

The director may adopt rules pursuant to title 41, chapter 6 to carry out this article.

A. The health care appeals fund is established consisting of monies collected pursuant to subsection B of this section. The fund is a special state fund pursuant to section 35-142, subsection A, paragraph 8. Monies in the fund do not revert to the state general fund. The departme…

The director may assess each health care insurer that is authorized to transact insurance: 1. A single fee of not more than $200 per insurer. 2. Up to $200 each year for the costs of performing the responsibilities relating to the procurement of independent review organizations a…

[Repealed or reserved.]

In this chapter, unless the context otherwise requires: 1. "Affiliate" means a person who directly or indirectly controls, is controlled by or is under common control with an insurer, a person who for a specific fee or commission regularly furnishes investment advice to an insure…

A. An insurer shall not deliver or issue for delivery in this state a variable life insurance policy unless all of the following apply: 1. The insurer is licensed to transact life insurance business in this state. 2. The director gives written approval to the insurer for the issu…

A. In addition to any other materials an insurer is required to submit to the director pursuant to this article, an insurer authorized to transact variable life insurance business in this state shall submit the following to the director: 1. An annual statement of the business of …

A. Except pursuant to chapter 5, article 1 of this title, the director shall not approve a variable life insurance form unless the insurer files with the director its variable life insurance policies, and all riders, endorsements, applications and other documents that are attache…

A. Reserve liabilities for variable life insurance policies shall be established under section 20-510 according to actuarial procedures that recognize the variable nature of the benefits provided and any mortality guarantees. B. Reserve liabilities for the guaranteed minimum deat…

A. A domestic insurer issuing variable life insurance contracts shall establish one or more separate accounts pursuant to section 20-651. The following apply to the establishment of separate accounts: 1. If no law governs the custody of separate account assets and if the insurer …

A. An insurer that delivers or issues for delivery in this state a variable life insurance policy shall deliver the following information to the applicant for the policy: 1. A summary explanation of the principal features of the policy. The summary explanation shall be in nontech…

A variable life insurance policy application shall contain all of the following: 1. A prominent statement that the death benefit may be variable or fixed under specified conditions. 2. A prominent statement that cash values may increase or decrease according to the investment exp…

An insurer that delivers or issues for delivery in this state a variable life insurance policy shall send the following reports to each variable life insurance policyholder: 1. Within thirty days after each anniversary of the policy, a statement or statements of the cash surrende…

If the laws of a foreign company's domiciliary state provide a degree of protection to the policyholders and the public that is substantially similar to the degree of protection that is provided by this article, the director may determine that the foreign company has complied wit…

In this article, unless the context otherwise requires: 1. "Company" means an insurer licensed pursuant to this title to transact life insurance or annuities in this state. 2. "Variable annuity" means an individual policy or contract that provides for annuity benefits that vary a…

A. A company shall not issue or issue for delivery in this state variable annuities unless the director is satisfied that the company's condition or method of operation in connection with the issuance of variable annuity contracts will not be hazardous to the public or the compan…

A. A domestic company that issues variable annuities shall establish one or more separate accounts pursuant to section 20-651. B. Except pursuant to subsection C of this section: 1. The company may invest and reinvest amounts that are allocated to a separate account and accumulat…

Unless exempt pursuant to chapter 5, article 1 of this title, each insurer shall file with the director all variable annuity contracts and all riders, endorsements, applications and other documents that are attached to and made part of the contract and that relate to the variable…

A. A variable annuity that provides benefits payable in variable amounts and that is delivered or issued for delivery in this state shall contain a statement of the essential features of the procedures the insurance company must follow in determining the dollar amount of the vari…

A. This section does not apply to the following: 1. Reinsurance. 2. Group annuity contract purchases that are made in connection with one or more retirement or deferred compensation plans that are established or maintained by or for one or more employers, including partnerships o…

A. At least once in each contract year after the first contract year, a company that issues individual variable annuities shall send to the contract holder at the contract holder's last known address a statement reporting the investments that are held in the separate account as o…

If the law in a foreign company's domiciliary state provides a degree of protection to the policyholders and the public that is substantially equal to the degree of protection that is provided by this article, the director may determine that the foreign company has complied with …

A. This article applies to all agents as defined in section 20-2601 seeking qualification to sell or offer for sale variable contracts or variable group contracts in this state. B. In this article, unless the context otherwise requires: 1. "Variable contracts" means a variable li…

A. A person may not sell or offer for sale in this state any variable contracts unless the person is licensed as a life insurance producer by the department and files with the director evidence that the person is licensed by the financial industry regulatory authority as a princi…

In this chapter, unless the context otherwise requires: 1. "Coverage" means the contractual obligation of a health care services plan to pay its enrollee or a contracted or noncontracted provider for medically necessary emergency services rendered by the provider to an enrollee, …

A. This chapter does not apply to: 1. A provider employed by or under contract with the enrollee's health care services plan. 2. A health care services plan administered under title 36. 3. A health care services plan that only covers health care expenses incurred by an enrollee w…

A. A health care services plan shall provide coverage for an initial medical screening examination and any immediately necessary stabilizing treatment required by the emergency medical treatment and active labor act (P.L. 99-272; 100 Stat. 164; 42 United States Code section 1395d…

A. A health care services plan engaging in utilization review to determine whether any emergency services rendered by a provider were medically necessary and in accordance with this chapter shall consider the following factors: 1. Current emergency medical literature and standard…

In this article, unless the context otherwise requires: 1. "Applicant" means a provider organization that submits an application to the contractor to provide continuing education courses. 2. "Approved continuing education course" means any course that has been approved by at leas…