(a) Benefit determination notification timelines.  A healthcare entity and/or its review agent shall comply with the following:

(1)  For urgent or emergent healthcare services, benefit determinations (adverse or non-adverse) shall be made as soon as possible taking into account exigencies but not later than 72 hours after receipt of the claim.

(2)  For concurrent claims (adverse or non-adverse), no later than twenty-four (24) hours after receipt of the claim and prior to the expiration of the period of time or number of treatments. The claim must have been made to the healthcare entity or review agent at least twenty-four (24) hours prior to the expiration of the period of time or number of treatments.

(3)  For pre-service claims (adverse or non-adverse), within a reasonable period of time appropriate to the medical circumstances, but not later than fifteen (15) calendar days after the receipt of the claim. This may be extended up to fifteen (15) additional calendar days if required by special circumstances and claimant is noticed within the first fifteen (15) calendar-day period.

(4)  For post-service claims adverse benefit determination no later than thirty (30) calendar days after the receipt of the claim. This may be extended for fifteen (15) calendar days if substantiated and claimant is noticed within the first thirty (30) calendar day period.

(5)  Provision in the event of insufficient information from a claimant.

(i)  For urgent or emergent care, the healthcare entity or review agent must notify claimant as soon as possible, depending on exigencies, but no later than twenty-four (24) hours after receipt of claim giving specifics as to what information is needed. The healthcare entity or review agent must allow claimant at least forty-eight (48) hours to send additional information. The healthcare entity or review agent must provide benefit determination as soon as possible and no later than forty-eight (48) hours after receipt of necessary additional information or end of period afforded to the claimant to provide additional information, whichever is earlier.

(ii)  For pre-service and post-service claims, the notice by the healthcare entity or review agent must include what specific information is needed. The claimant has forty-five (45) calendar days from receipt of notice to provide information.

(iii)  Timelines for decisions, in the event of insufficient information, are paused from the date on which notice is sent to the claimant and restarted when the claimant responds to the request for information.

(b) Adverse benefit determination notifications form and content requirements.  Healthcare entities and review agents shall comply with form and content notification requirements, to include the following:

(1)  Notices may be written or electronic with reasonable assurance of receipt by claimant unless urgent or emergent. When urgent or emergent, oral notification is acceptable, absent a specific request by claimant for written or electronic notice, followed by written or electronic notification within three (3) calendar days.

(2)  Notification content shall:

(i)  Be culturally and linguistically appropriate;

(ii)  Provide details of a claim that is being denied to include date of service, provider, amount of claim, a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning as applicable;

(iii)  Give specific reason or reasons for the adverse benefit determination;

(iv)  Include the reference(s) to specific health benefit plan or review agent provisions, guideline, protocol, or criterion on which the adverse benefit determination is based;

(v)  If the decision is based on medical necessity, clinical criteria or experimental treatment or similar exclusion or limit, then notice must include the scientific or clinical judgment for the adverse determination;

(vi)  Provide information for the beneficiary as to how to obtain copies of any and all information relevant to the denied claim free of charge;

(vii)  Describe the internal and external appeal processes, as applicable, to include all relevant review agency contacts and OHIC’s consumer assistance program information;

(viii)  Clearly state timeline that the claimant has at least one hundred eighty (180) calendar days following the receipt of notification of an adverse benefit determination to file an appeal; and

(ix)  Be written in a manner to convey clinical rationale in layperson terms when appropriate based on clinical condition and age and in keeping with federal and state laws and regulations.