Title 44 — Charitable and Curative Institutions.

For the purposes of this chapter, the term (1) “Adverse benefit determination” means a denial, reduction, limitation, termination, failure to make a payment for a benefit, or a delay of a benefit to a member, regarding determinations about: (A) The medical necessity, appropriaten…

(a) The provisions of subchapter I of this chapter shall not apply in cases directly involving coverage determinations or benefit requirements under the federal Medicare program. The provisions of subchapters II and III of this chapter shall not apply in cases directly involving …

(a)(1) A member or member representative shall have a right to file an appeal with an insurer for a review of an adverse benefit determination. An insurer’s health benefits plan shall include an appeal system that provides for the presentation and resolution of appeals brought by…

(a) A member or member representative may appeal any adverse benefit determination decision resulting in a rescission, denial, termination, or other limitation of a benefit in accordance with the provisions of this chapter. (b) At the time an insurer denies, reduces, terminates, …

Repealed Repealed.

(a)(1) An insurer shall establish and maintain an internal appeals process whereby a member or member representative who has received an adverse benefit determination can have the opportunity to pursue an appeal before a reviewer or panel of physicians, a mental health profession…

If an insurer denies a member or member representative’s appeal of a rescission, the insurer shall provide the member or member representative and the Department of Insurance, Securities, and Banking with a written explanation of why the insurer found that there was fraud or misr…

(a) The Director shall establish and maintain an external appeals process whereby a member or member representative who is dissatisfied with a decision rendered in an internal appeals process shall have the opportunity to pursue an external appeal before an independent review org…

(a) Each independent review organization selected by the Director to review external appeals must be certified every 2 years by the Director. (b) The Director shall be responsible for developing, applying, and enforcing certification standards for independent review organizations…

The Mayor shall assess all insurers to cover all the costs of administering this chapter. The Mayor shall promulgate regulations to determine the assessment formula.

(a) Every insurer shall submit to the Director, an annual grievance report, that chronicles all grievance activity during the preceding year. The Director shall develop a system for classifying and categorizing grievances and appeals that all insurers and independent review organ…

A group health plan that is located in the District but that is not subject to District regulation may voluntarily use the District’s external review system; provided, that it pays the full costs of external review and adheres to the procedures set forth in § 44-301.07.

(a) A health benefits plan shall permit a member with chronic disabling or life threatening conditions to choose a health care specialist as the member’s primary care provider. The specialist must be a participant in the health benefits plan and be available to attend to the memb…

(a) In general, subject to subsection (b) of this section, a health benefits plan shall permit a member to receive medically necessary or appropriate specialty care for more than one visit without having to obtain the insurer’s approval for subsequent visits authorized by a prima…

(a) Every health benefits plan that requires or provides a member with the opportunity to designate a participating primary care provider, shall permit a member who is female to designate as her primary care provider a participating physician or advance practice registered nurse …

If a contract between an insurer and a health care provider is terminated by either party for any reason other than termination for failure to meet applicable quality standards of care or fraud, and a member is undergoing a course of treatment from the physician at the time of th…

(a) Within 120 days of April 27, 1999, the Director shall promulgate any regulations and standards as may be necessary to carry out the purposes of this chapter. (b) Health benefits plans and insurers subject to this chapter shall comply with the regulations promulgated pursuant …