(a)(1) An insurer shall establish and maintain an internal appeals process whereby a member or member representative who has received an adverse benefit determination can have the opportunity to pursue an appeal before a reviewer or panel of physicians, a mental health professional, advanced practice registered nurses, or other health care professionals selected by the insurer.

(2) Group health plans and individual health insurers shall follow claims procedures established pursuant to the Employee Retirement Income Security Act of 1974, approved September 2, 1974 (Pub. L. No. 93-406; 88 Stat. 829), Title XXVII of the Public Health Service Act, approved July 1, 1944 (42 U.S.C. § 300gg et seq.), and the Patient Protection and Affordable Care Act, approved March 23, 2010 (124 Stat. 119; 42 U.S.C. § 18001, note), as amended by the Health Care and Education Reconciliation Act of 2010, approved March 30, 2010 (124 Stat. 1029; 42 U.S.C. § 1305, note), if applicable. At a minimum, the member or member’s representative shall be allowed to request an internal review within 180 days of receipt of a notice of an adverse benefit determination.

(b) Reviews shall be in accordance with the following:

(1) The reviewer or panel selected by the insurer pursuant to subsection (a) of this section shall not have been involved in the adverse benefit determination decision under review.

(2) For all reviews requiring medical expertise or mental health expertise, the review panel shall include at least one medical reviewer who is trained or certified in the same specialty as the matter at issue.

(3) A medical reviewer shall be a physician, a mental health professional, an advanced practice registered nurse, or other appropriate health care provider possessing a non-restricted license to practice or provide care anywhere in the United States and the District of Columbia and have no history of disciplinary action or sanctions taken or pending against him or her by any governmental or professional regulatory body.

(4) A medical reviewer shall be certified by a recognized specialty board in the areas appropriate to the review.

(5) The health insurer shall ensure the independence and impartiality of the individuals making review decisions. The health insurer shall not make decisions related to such individuals regarding hiring, compensation, termination, promotion, or other similar matters based upon the likelihood that the individual will support the denial of benefits.

(6)(A) For claims involving mental health care, the confidentiality of mental health information shall be preserved pursuant to Chapter 12 of Title 7 [§ 7-1201.01 et seq.]. Pursuant to a valid authorization, the provider may share limited information as described in § 7-1203.03 to determine payment.

(B) The patient may authorize (or for participating providers, the provider and insurer may jointly authorize) review of the patient’s record of mental health information by an independent mental health professional. Mental health information disclosed to an independent mental health professional under these procedures shall not be disclosed to the health insurer.

(c) All internal appeals shall be acknowledged by the insurer, in writing, to the member or member representative filing the appeal within 10 business days of receipt.

(d) The member and the member’s representative shall have the right to:

(1) Review the member’s file;

(2) Request and receive free of charge copies of all documents and records relevant to the claim;

(3) Present evidence and testimony as part of the appeals process;

(4) Review any new or additional evidence considered or generated by the health insurer;

(5) Review any new or additional rationale used by the insurer in connection with the claim; and

(6) Sufficient opportunity to respond.

(e) The member has the right to continued coverage, upon request, at the level of benefits provided before the reduction, termination, or limitation, pending the outcome of the appeal.

(f) An internal appeal shall be conducted as soon as possible after receipt by the insurer of all necessary documentation in accordance with the medical exigencies of the case. If the internal appeal is from a decision regarding urgent or emergency medical conditions, the insurer shall conclude the appeal within 24 hours of the notification of appeal by the member or member representative. The health insurer shall conclude all other appeals conducted pursuant to this section within 30 calendar days for prospective reviews and 60 calendar days for retrospective reviews.

(g) If an insurer denies a member’s or member representative’s internal appeal, the insurer shall provide the member or member representative with a written explanation of the denial and written notification of his or her right to receive copies of all documents relevant to the claim and to proceed to an external appeal. The notification shall include specific instructions as to how the member or member representative may arrange for an external appeal and any forms required to initiate an external appeal.

(h) At a minimum, the written explanation provided by the insurer of the determination pursuant to subsection (g) of this section shall include:

(1) The reviewer’s understanding of the member’s or member representative’s complaint;

(2) Information sufficient to identify the claim involved, including, if applicable:

(A) The date of service;

(B) The health care provider;

(C) The claim amount; and

(D) A statement describing the availability, upon request, of the diagnosis code and its corresponding meaning and the treatment code and its corresponding meaning;

(3) The reviewer’s decision in clear terms;

(4) The title and qualifying credentials of the person or persons participating in the review, including how those credentials apply to the specific form of treatment being reviewed;

(5) The contractual basis, including reference to specific plan provisions, or medical rationale in enough detail for the member or member representative to understand and to respond to the insurer’s position;

(6) A reference to the evidence or documentation used as the basis for the decision, including internal rules, guidelines, and protocols; and

(7) All applicable instructions, including the telephone numbers and titles of persons to contact and the time frames in which to appeal the decision to the next stage of appeal.

(i) If the insurer fails to comply with any of the deadlines or procedures for completion of an internal appeal or if that further participation in the internal process would require the provision of mental health information that the patient or treating mental health professional considered confidential, the member or member representative shall be relieved of his or her obligation to complete the internal review process and may, at his or her option, proceed directly to the external appeals process required by § 44-301.07.

(Apr. 27, 1999, D.C. Law 12-274, § 106, 46 DCR 1294; Mar. 19, 2013, D.C. Law 19-229, § 2(e), 59 DCR 13592.)

1981 Ed., § 32-571.6.

This section is referenced in § 44-301.03 and § 44-301.07.

The 2013 amendment by D.C. Law 19-229 rewrote the section.