18 Del. Admin. Code § 1301-3.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1301-3.0 - Minimum Requirements for an Internal Review Process (IRP)

3.1 In addition to the requirements set forth in 18 Del.C. § 332, the provisions of this section shall govern the internal review process of all carriers offering health insurance in Delaware:

3.2 All written procedures and forms utilized by a carrier shall be readable and understandable by a person of average intelligence and education. All such documents shall meet the following criteria:

3.2.1 The type size shall not be smaller than 11 point;

3.2.2 The type style selection shall be at the discretion of the carrier but shall be of a type that is clear and legible;

3.2.3 Captions or headings shall be designed to stand out clearly;

3.2.4 White space separating subjects or sections should be distinct;

3.2.5 There must be included a table of contents sufficient to guide and assist the covered person or his authorized representative;

3.2.6 Where appropriate, definitions shall be included, shall be sufficient to clearly apply to the usage intended, and shall not conflict with the definitions contained in this regulation; and

3.2.7 The forms shall be written in everyday, conversational language to the extent possible to preserve the legal meaning.

3.2.8 Short familiar words shall be used and sentences shall be kept as short and simple as possible.

3.3 The carrier shall provide all forms relating to grievances, appeals, arbitration or other procedures relating to IRP as examples along with the written notice of IRP provided to the covered person.

3.4 Written notice.

3.4.1 For any IRP not previously approved by the Department, the carrier shall provide written notice of the IRP to all covered persons within 30 days of approval by the Department.

3.4.2 The carrier shall provide the notice required by 18 Del.C. § 332(c)(1) to covered persons following any adverse determination, and annually, either upon the policy renewal date, open enrollment date, or a set date for all covered persons, in the carrier's discretion. In addition to the requirements set forth in 18 Del.C. § 332(c)(1), the notice shall also, at a minimum, provide as follows:

3.4.2.1 You have the right to seek a review of a claim reduction or denial through this insurer's internal review process.

3.4.3 For every new policy issued after the Department's approval of the IRP, the carrier shall provide covered persons with a copy of the IRP at the time, or prior to the time, the carrier sends identification cards, member handbooks or similar member materials to newly covered persons.

3.4.4 When a covered person's dependents are also covered, a single notice to the principal covered person shall be sufficient under this section.

3.5 Under circumstances where an oral or written grievance may not contain sufficient information and the carrier requests additional information, such request shall not be burdensome or require such information as the carrier might reasonably be expected to obtain through its normal claims process.

18 Del. Admin. Code § 1301-3.0

21 DE Reg. 580 (1/1/2018)
26 DE Reg. 873 (4/1/2023) (Final)