Title 56, Insurance

(a) A health carrier shall maintain written records to document all grievances received during a calendar year. The register shall be maintained in a manner that is reasonably clear and accessible to the commissioner. (b) A request for a first level review of a grievance involvin…

(a) Except as specified in § 56-61-109, a health carrier shall use written procedures for receiving and resolving grievances from aggrieved persons, as provided in §§ 56-61-107 and 56-61-108, unless otherwise provided by this chapter. (b) A health carrier shall file with the comm…

(a) Within one hundred and eighty (180) days after the date of receipt of a notice of an adverse determination, an aggrieved person may file a grievance with the health carrier requesting a first level review of the adverse determination. (b) The health carrier shall provide the …

(a) A health carrier shall establish a second level review process to give aggrieved persons, who are dissatisfied with the first level review decision, the option of requesting a second level review. (b) (1) Health carriers required by this section to establish a second level re…

(a) A health carrier shall establish written procedures for the expedited review of urgent care requests of grievances involving an adverse determination. (b) In addition to subsection (a), a health carrier shall provide expedited review of a grievance involving an adverse determ…

The commissioner may, after notice and hearing, promulgate reasonable rules and regulations to carry out this chapter. Such rules and regulations shall be subject to review in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5.

A person that violates this chapter shall be subject to the penalties set forth in § 56-2-305.

(a) For purposes of this section, “approved entity” means:(1) The utilization review accreditation commission (URAC); or(2) Other nationally recognized private accrediting entity employing standards for the accreditation of external review programs that the commissioner deems are…

(a) A health carrier shall notify the aggrieved person in writing of the right to request an external review to be conducted pursuant to §§ 56-61-116 and 56-61-118 and include the appropriate statements and information set forth in subsection (b) at the same time that the health …

(a) Except for a request for an expedited external review as set forth in § 56-61-117 or § 56-61-118(n), all requests for external review shall be made in writing to the health carrier. (b) Unless otherwise set forth by this chapter, an aggrieved person may file a request for ext…

(a) Except as provided in subsection (b), a request for an external review pursuant to § 56-61-116 or § 56-61-118 shall not be made until the aggrieved person has exhausted the health carrier's internal grievance process as set forth in this chapter.(1) An aggrieved person shall …

(a) Within six (6) months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to § 56-61-113, an aggrieved person may file a request for an external review with the health carrier. (b) Within ten (10) business days following t…

(a) Except as provided in subsection (f), an aggrieved person may make a request for an expedited external review with the health carrier at the time the aggrieved person receives:(1) An adverse determination if:(A) The adverse determination involves a medical condition of the co…

(a) Within six (6) months after the date of receipt of a notice of an adverse determination or final adverse determination that involves a denial of coverage based on a determination that the healthcare service or treatment recommended or requested is investigational, an aggrieve…

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

(a) The commissioner shall approve external review organizations eligible to conduct external reviews under this chapter. (b) In order to be eligible for approval by the commissioner to conduct external reviews under this chapter, an external review organization:(1) Except as oth…

(a) To be approved under § 56-61-120 to conduct external reviews, an external review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process set forth in th…

No external review organization or clinical reviewer working on behalf of an external review organization or an employee, agent or contractor of an external review organization shall be liable in damages to any person for any opinions rendered or acts or omissions performed withi…

(a) (1) An external review organization conducting an external review pursuant to this chapter shall maintain written records in the aggregate by state and by health carrier on all requests for external review for which it conducted an external review during a calendar year and, …

The health carrier against which a request for a standard external review or an expedited external review is filed shall pay the cost of the external review organization for conducting the external review.

(a) Each health carrier shall include a description of the external review procedures in or attached to the membership booklet, provider manual, and health carrier's web site. The health carrier may include a description of the external review procedures in the policy, certificat…