(a)(1) A member or member representative shall have a right to file an appeal with an insurer for a review of an adverse benefit determination. An insurer’s health benefits plan shall include an appeal system that provides for the presentation and resolution of appeals brought by members or member representatives.

(2) Health insurers shall notify members when claims are denied, setting forth the reasons for the denial and procedures for appealing the determination through internal and external review. The notice shall be written in a manner calculated to be understood by the participant, in accordance with federal rules for group health plans promulgated by the U.S. Department of Labor, federal rules for individual health plans promulgated by the U.S. Department of Health and Human Services, and any rules promulgated by the Director pursuant to this chapter.

(3) All notices regarding adverse benefit determinations shall meet the requirements of the Patient Protection and Affordable Care Act of 2010, approved March 23, 2010 (Pub. L. No. 111-148; 124 Stat. 119), regarding cultural and linguistic appropriateness, and, if the insurer is a subcontractor or grantee of a covered entity, as that term is defined in the Language Access Act of 2003, effective June 19, 2004 (D.C. Law 15-167; D.C. Official Code § 2-1931 et seq.)(“Language Access Act”), shall also meet the language access standards under the Language Access Act. At a minimum, insurers shall include information in languages identified by the Director about how to obtain free oral interpretation and translation of notices and vital documents.

(b) An appeal system established pursuant to this section shall, at a minimum, incorporate the following components:

(1) The right of a member to file an appeal regarding any aspect of the insurer’s health care services;

(2) The right of a member to file an appeal regarding an insurer’s decision to rescind coverage;

(3) A procedure for filing an appeal from an adverse benefit determination;

(4) A standardized method of recording, documenting, and reporting the status of all adverse benefit determinations and appeals, which includes the requirements that a health insurer maintain for 6 years records of all claims, and notices associated with the claims, grievances, appeals, and the review process, and limit access to patient-identifying information in those records in accordance with the Health Insurance Portability and Accountability Act of 1996, approved August 21, 1996 (Pub. L. No. 104-191; 110 Stat. 1936), and any other applicable patient confidentiality rules;

(5) Availability of a member services representative to assist members with grievances and appeals upon request;

(6) The right of a member to designate an outside independent representative to assist the member or member representative in following the grievance procedures upon request;

(7) A specified time for responding to appeals not to exceed the time frames set forth in § 44-301.06(f), from receipt of the grievance by the insurer;

(8) An oral and written procedure describing how grievances and appeals are processed and resolved;

(9) Procedures for insurers to follow concerning the methods to be used to inform the member of the resolution; and

(10) In the case of appeals regarding emergency or urgent medical conditions, procedures that will allow a member or member representative to immediately request an expedited review in accordance with §§ 44-301.06 and 44-301.07.

(c) At the time a member first enrolls with an insurer, the insurer shall provide each member with written notice of the components required in subsection (b)(1) through (3) of this section, as well as:

(1) The telephone numbers and business addresses of the insurer’s representatives responsible for grievance resolution;

(2) The telephone number, business address, and description of the Health Care Ombudsman’s services;

(3) A statement that describes the member’s or member representative’s right to contact the Director, or the Director’s designee, to seek external review if dissatisfied with the resolution reached through the insurer’s grievance system; and

(4) A statement that describes a Medicaid or D.C. Health Care Alliance enrollee’s right to appeal to the Office of Administrative Hearings at any time, if applicable.

(d) In the case of a reduction or a termination of services that is contrary to the recommendations of the treating physician, mental health professional, or advance practice registered nurse, an insurer shall provide a member or member representative with 24 hours prior verbal notification, followed by a written decision as soon as practical.

(e) An insurer shall include in the “evidence of coverage” and “member handbook” issued to members a description of the procedures for filing grievances and appeals.

(f) An insurer shall not take retaliatory action of any sort against a member who files a grievance pursuant to this section or an appeal pursuant to §§ 44-301.06 and 44-301.07.

(g) The Director or the Director’s designee shall waive exhaustion of the appeal process required by § 44-301.06 as a prerequisite for proceeding to the external appeal process:

(1) In cases of emergency or urgent medical conditions;

(2) If the insurer has not complied with the requirements of the internal review process; or

(3) If further participation in the internal appeal process would require the provision of mental health information that the patient or treating mental health professional considered confidential.

(Apr. 27, 1999, D.C. Law 12-274, § 103, 46 DCR 1294; Mar. 19, 2013, D.C. Law 19-229, § 2(b), 59 DCR 13592.)

1981 Ed., § 32-571.3.

This section is referenced in § 44-301.07.

The 2013 amendment by D.C. Law 19-229 rewrote (a)-(c); added “mental health professional” in (d); substituted “§§ 44-301.06 and 44-301.07” for “§ 44-301.05” in (f); and rewrote (g).