Sections 38.2-3559 through 38.2-3562 of the Code of Virginia relating to health carriers, expedited reviews of adverse coverage determinations, exhaustion of internal reviews and cancer patients was enacted on April 3, 2019. To view the enacted bills, please click here.
The purpose of this regulation is to reflect changes to bring the Benefit Determination and Utilization Review Act to current national protective standards to assure that benefit determination agencies maintain timely approval and payment for covered health care services to health care entity beneficiaries. In addition, it provides clarity for in these regulations assure quality, […]
A bulletin was issued regarding the Annual Survey on Health Insurance requirement that is applicable to all insurers authorized to transact health insurance business in the state of Alaska and other interested parties. To view the bulletin, please click here.
Does the state have an ER provision? Timeframe Standard Appeals Timeframe Expedited Appeal Timeframe Experimental Appeal ACA Compliant? Alabama No No Alaska Yes 45 days 72 hours 20 days Yes, NAIC-parallel Arizona Yes 21 days (medical necessity);15 days (coverage) 72 hours (medical necessity); 2 days (coverage) No provision. Yes, meets similar Arkansas Yes 45 […]
Table 3: Key Program Requirements Clinical Review Criteria Prohibition Against Financial Incentives Telephonic Coverage Specified Quality Assurance Program Delegated Oversight UM Reviewer Requirements Medical Director Requirements Same State Licensure Requirement Offshore Reviews Permitted Alabama x x x x x Alaska x x x x x x American Samoa Arizona x x x x x […]
Table 2: Organizational Registration/Licensure Requirements States Licensure/ Certification Requirements Details Renewal Period Initial Licensure Fee Licensure Documentation Requirement(s) Accreditation Deemed Status Alabama Yes Annually $1,000* Yes Yes Alaska No Arizona Yes Every 3 Years No amount provided Yes Yes Arkansas Yes Biennial $1,250 Yes No California No Colorado No Connecticut Yes Annually $3,000 Yes Yes Delaware […]
Table 4: Review & Appeals Internal UM Appeal Levels Notice Of Appeal Rights in Adverse Determination Required Timeframe Standard Appeal Timeframe Expedited Appeal Extension Option Final Notification Requirement(s) Alabama Yes 30 days 48 hours Yes Alaska Arizona 2 Yes 30 days (Informal Appeal or Formal Appeal); 60 days (Formal Appeal for Retrospective Decision) 1 day […]
Table 1: UM Regulations: State Scope & Applicability States UM Regulations in State Organizational Type HMO Insurer URO ACO PPO TPA Exemptions? Alabama x x x x x x x x Alaska x x x x x x x American Samoa Arizona x x x x x x x x Arkansas x x x x […]
Administrative Letter 2019-02 was issued to provide guidance for the submission of complaint system filings, notice and policy form requirements to comply with the provisions of Chapter 826 (House Bill 1915) and Chapter 840 (Senate Bill 1161) enacted by the General Assembly during its 2019 legislative session. To view the Administrative Letter, please click here.
The United States District Court for the Northern District of California recently held that United Behavioral Health illegally denied mental health and substance use coverage based on flawed medical necessity criteria. To view the full decision, please click here.