N.H. Admin. Code § Ins 2703.04

Current through Register No. 45, November 7, 2024

Section Ins 2703.04 - Notice of Right to External Review

(a) Health carriers shall provide to covered persons the insurance department's "Managed Care Consumer Guide to External Appeal" and the insurance department's "Request for Independent External Appeal of a Health Care Decision" in each of the following circumstances:

(1) The publications shall be attached to the policy, certificate, membership booklet, or other evidence of coverage provided to covered persons;

(2) The publications shall be included with the final adverse determination provided to covered persons upon completion of internal grievance review or expedited internal grievance review;

(3) If the health carrier agrees to submit the determination to independent external review prior to completion of internal review, the publications shall be provided at the time such agreement is made; and

(4) If the covered person has requested standard or expedited internal grievance review, and the health carrier has failed to issue a decision within the required time frames, the publications shall be provided promptly upon the expiration of the time period for issuing the decision.

(b) Pursuant to the provisions of RSA 420-J:5, V. (a) (3), a notice shall be included with the final determination provided to covered persons upon completion of standard internal grievance review or expedited internal grievance review.

(c) The notice in (b) above shall be:

(1) In bold;

(2) Set out in at least 16 point type, and the remainder of the text in at least 12 point type; and

(3) Printed as follows:

"NOTICE OF RIGHT TO AN EXTERNAL APPEAL OF YOUR HEALTH INSURER'S DECISION

This is our final decision in the internal grievance review process. You may have a legal right to have our decision reviewed by an organization that is independent and neutral. This process is called Independent External Review and is overseen by the New Hampshire Insurance Department. There is no cost to you for an external appeal.

YOU MUST ASK FOR THIS REVIEW NO LATER THAN 180 DAYS AFTER THE DATE OF THIS NOTICE

To request an independent external review, consult the enclosed Managed Care Consumer Guide to External Appeal, fill out the enclosed Request for Independent External Appeal of a Health Care Decision, and attach all supporting documentation."

(d) The person seeking external review shall mail or deliver the completed request to the New Hampshire insurance department at:

Independent External Review

New Hampshire Insurance Department

21 South Fruit Street, Suite 14

Concord, NH 03301

(e) The notice in (b) above shall also include a statement as follows:

"If your medical condition is such that waiting for the standard external review process to be completed would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function, you may be eligible for expedited external review.

If you have any questions about the external review process, please call the New Hampshire Insurance Department at 1-800-852-3416 and ask to speak to a consumer assistant."

(f) Pursuant to the provisions of RSA 420-J:5, V (a)(3), if the health carrier agrees to submit the determination to independent external review prior to completion of internal review, the following notice shall be provided to the covered person at the time of the agreement:

(g) The notice in (f) above shall be:

(1) In bold;

(2) Set out in at least 16 point type, and the remainder of the text in at least 12 point type; and

(3) Printed as follows:

"NOTICE OF RIGHT TO AN EXTERNAL APPEAL OF YOUR HEALTH INSURER'S DECISION

We have agreed to submit your appeal of our determination to an independent reviewer prior to completion or our internal grievance review process. This means that you may now have our decision reviewed by an organization that is independent and neutral. This process is called Independent External Review and is overseen by the New Hampshire Insurance Department. There is no cost to you for an external appeal.

YOU MUST ASK FOR THIS REVIEW NO LATER THAN 180 DAYS AFTER THE DATE OF THIS NOTICE

To request an independent external review, consult the enclosed Managed Care Consumer Guide to External Appeal, fill out the enclosed Request for Independent External Appeal of a Health Care Decision, and attach all supporting documentation.

(h) The person seeking external review shall mail or deliver the completed request to the New Hampshire insurance department at:

Independent External Review

New Hampshire Insurance Department

21 South Fruit Street, Suite 14

Concord, NH 03301

(i) The notice in (f) above shall also include a statement as follows:

"If your medical condition is such that waiting for the standard external review process to be completed would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function, you may be eligible for expedited external review.

If you have any questions about the external review process, please call the New Hampshire Insurance Department at 1-800-852-3416 and ask to speak to a consumer assistant."

(j) Pursuant to RSA 420-J:5, V (a)(3), if the covered person has requested standard or expedited internal grievance review and the health carrier has failed to issue a decision within the required time frames, the health carrier shall send the following notice to the covered person promptly upon the expiration of the time period for issuing the decision:

(k) The notice in (j) above shall be:

(1) In bold;

(2) Set out in at least 16 point type, and the remainder of the text in at least 12 point type; and

(3) Printed as follows:

"NOTICE OF RIGHT TO AN EXTERNAL APPEAL OF YOUR HEALTH INSURER'S DECISION

We have agreed to submit your appeal of our determination to an independent reviewer prior to completion or our internal grievance review process. This means that you may now have our decision reviewed by an organization that is independent and neutral. This process is called Independent External Review and is overseen by the New Hampshire Insurance Department. There is no cost to you for an external appeal.

YOU MUST ASK FOR THIS REVIEW NO LATER THAN 180 DAYS AFTER THE DATE OF THIS NOTICE

To request an independent external review, consult the enclosed Managed Care Consumer Guide to External Appeal, fill out the enclosed Request for Independent External Appeal of a Health Care Decision, and attach all supporting documentation."

(1) The person seeking external review shall mail or deliver the completed request to the New Hampshire insurance department at:

Independent External Review

New Hampshire Insurance Department

21 South Fruit Street, Suite 14

Concord, NH 03301

(m) The notice in (j) above shall also include a statement as follows:

"If your medical condition is such that waiting for the standard external review process to be completed would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function, you may be eligible for expedited external review. If you have any questions about the external review process, please call the New Hampshire Insurance Department at 1-800-852-3416 and ask to speak to a consumer assistant."

N.H. Admin. Code § Ins 2703.04

#7539, eff 8-1-01; ss by #8862, eff 5-1-07 Ins 2703.05

Amended by Volume XXXV Number 36, Filed September 10, 2015, Proposed by #10918, Effective 9/1/2015, Expires9/1/2025.