Section 58-17C-52 - Notification of adverse determination--Contents.
58-17C-52. Notification of adverse determination--Contents. Any notification of an adverse determination under this section shall, in a manner which is designed to be understood by the covered person, set forth:
(1) The specific reason or reasons for the adverse determination;
(2) A reference to the specific plan provision on which the determination is based;
(3) A description of additional material or information necessary for the covered person to complete the benefit request, including an explanation of why the material or information is necessary to complete the request;
(4) A description of the health carrier's grievance procedures established pursuant to §§ 58-17C-80 to 58-17C-102, inclusive, including time limits applicable to those procedures;
(5) If the health carrier relied upon an internal rule, guideline, protocol, or other similar criterion to make the adverse determination, either the specific rule, guideline, protocol, or other similar criterion or a statement that a specific rule, guideline, protocol, or other similar criterion was relied upon to make the adverse determination and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to the covered person upon request;
(6) If the adverse determination is based on a medical necessity or experimental or investigational treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the determination, applying the terms of the health benefit plan to the covered person's medical circumstances or a statement that an explanation will be provided to the covered person free of charge upon request;
(7) If applicable, instructions for requesting:
(a) A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the adverse determination, as provided in subdivision (5) of this section; or
(b) The written statement of the scientific or clinical rationale for the adverse determination, as provided in subdivision (6) of this section; and
(8) A statement explaining the right of the covered person, as appropriate, to contact the Division of Insurance at any time for the assistance or, upon completion of the health carrier's grievance procedure process as provided under §§ 58-17C-80 to 58-17C-102, inclusive, to file a civil suit in a court of competent jurisdiction.
A health carrier may provide the notice required under this section in writing or electronically.
Source: SL 1999, ch 243, § 20; SL 2003, ch 250, § 10.