§ 56-61-106. Written Procedures for Grievances
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. A health carrier shall file with the commissioner a copy of the procedures required under subsection (a), including all forms used […]
§ 56-61-107. First Level Review of Adverse Determination
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. The health carrier shall provide the aggrieved person with the name and address of the organizational […]
§ 56-61-108. Second Level Review of Adverse Determination
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. Health carriers required by this section to establish a second level review process shall provide aggrieved persons with notice pursuant to § 56-61-107, as […]
§ 56-61-109. Establishment of Written Procedures for Expedited Review of Urgent Care Requests of Grievances Involving Adverse Determination
A health carrier shall establish written procedures for the expedited review of urgent care requests of grievances involving an adverse determination. In addition to subsection (a), a health carrier shall provide expedited review of a grievance involving an adverse determination with respect to concurrent review of urgent care requests involving an admission, availability of care, […]
§ 56-61-110. Rules and Regulations
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.
§ 56-61-111. Penalties for Violations
A person that violates this chapter shall be subject to the penalties set forth in § 56-2-305.
§ 56-61-112. Elections for Conducting External Review Program
For purposes of this section, “approved entity” means: The utilization review accreditation commission (URAC); or Other nationally recognized private accrediting entity employing standards for the accreditation of external review programs that the commissioner deems are substantially equivalent to the standards for conducting an external review pursuant to §§ 56-61-113 — 56-61-118. A health carrier may […]
§ 56-61-113. Notice of Right to External Review
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 carrier sends written notice of a final adverse determination. […]
§ 56-61-114. Request for External Review
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. Unless otherwise set forth by this chapter, an aggrieved person may file a request for external review after the receipt of a final […]
§ 56-61-115. Exhaustion of Internal Grievance Process
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. An aggrieved person shall be considered to have exhausted the health carrier’s internal grievance […]