Disclosure of limitations on coverage -- Denial letter

(1) Any insurer that limits coverage for any treatment, procedure, a drug, or device shall define the limitations and fully disclose those limits in the health insurance policy or certificate coverage. (2) (a) Any insurer that denies coverage for a treatment, procedure, a drug that requires prior approval, or device for an enrollee shall provide the enrollee with a denial letter that shall include: 1. The state of licensure and title of the person making the decision; 2. A statement setting forth the specific medical and scientific reasons for denying coverage of a service, if the coverage is denied for reasons of medical necessity; and 3. Instructions for initiating or complying with the plan's grievance or appeal procedure stating at a minimum whether the appeal must be in writing, any time limitations or schedules for filing appeals and the name and phone number of a contact person who can provide additional information. (b) The denial letter shall be provided within: 1. Two (2) regular working days of the submitted request where preauthorization for a treatment, procedure, drug, or device is involved; 2. Twenty-four (24) hours of the submitted request where hospital preadmission review is sought; 3. Twenty (20) working days of the receipt of requested medical information where the plan has initiated a retrospective review; and 4. Twenty (20) working days of the initiation of the review process in all other instances.