No. 36035 (5-year Review): Rule R590-203. Health Grievance Review Process

DAR File No.: 36035
Filed: 04/05/2012 03:25:19 PM

NOTICE OF REVIEW AND STATEMENT OF CONTINUATION

Concise explanation of the particular statutory provisions under which the rule is enacted and how these provisions authorize or require the rule:

This rule is specifically authorized by Subsection 31A-22-629(4) and Section 31A-4-116, which require the commissioner to establish minimum standards for grievance review procedures. The rule is also promulgated pursuant to Subsections 31A-2-201(1) and 31A-2-201(3)(a) in which the commissioner is empowered to administer and enforce this title and to make rules to implement the provisions of this title. The authority to examine carrier records, files, and documentation is provided by Section 31A-2-203.

Summary of written comments received during and since the last five-year review of the rule from interested persons supporting or opposing the rule:

In 2011 this rule was changed twice. One comment was regarding the mistaken elimination of the term "medical necessity..." which was corrected in August. Another concern stated that the "adverse benefit determination was too broad". However, this language follows the wording in the statute. In November, the Department received a request that the implementation date be changed to an effective date and make it no sooner than 01/01/2012. The Department cannot put effective dates in the rule and to include an enforcement date would have meant another comment period which would have taken us beyond the 01/01/2012 date.

Reasoned justification for continuation of the rule, including reasons why the agency disagrees with comments in opposition to the rule, if any:

This rule clarifies statute and explains the difference between federal law and the state statutes. The rule ensures that a carrier's grievance review procedures for individual and group health insurance and disability income insurance plans comply with federal law. Removing this rule would confuse insurers as to what is required of them in regards to their grievance procedures. This rule provides protections for consumers. Therefore, this rule should be continued.

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Insurance
Administration
Room 3110 STATE OFFICE BLDG
450 N MAIN ST
SALT LAKE CITY, UT 84114-1201

Direct questions regarding this rule to:

• Jilene Whitby at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at [e-mail]

Authorized by:

Jilene Whitby, Information Specialist

Effective:

04/05/2012

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