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Notice of Proposed Changes on Health Care Insurer Utilization Review and Benefit Determinations, Grievance Procedures, and External Reviews; and Changes on Independent Review Organizations Including the Establishment of a Registration Fee

BRIEF DESCRIPTION

The Division of Insurance proposes to adopt regulation changes to provide standards and criteria relating to health care insurer utilization review and benefit determinations, grievance procedures, and external reviews; and changes relating to the registration and regulation of independent review organizations, including the establishment of a registration fee.

The Division of Insurance proposes to adopt regulation changes to Title 3, Chapter 28 and Chapter 31, of the Alaska Administrative Code including the following:

New Sections Added to Chapter 28

3 AAC 28.900 specifies the applicability requirements for health care insurer utilization review and benefit determinations.

3 AAC 28.902 requires health care insurer oversight of utilization review programs.

3 AAC 28.904 establishes requirements for when a health care insurer contracts to have a utilization review organization or other entity perform utilization functions.

3 AAC 28.906 establishes the scope and content of a utilization review program.

3 AAC 28.908 establishes operational requirements for a utilization review program.

3 AAC 28.910 establishes procedures for standard utilization review and benefit determinations.

3 AAC 28.912 establishes procedures for expedited utilization review and benefit determinations.

3 AAC 28.914 establishes procedures when conducting a utilization review or making a benefit determination for emergency services.

3 AAC 28.916 establishes confidentiality requirements for utilization review programs.

3 AAC 28.918 establishes disclosure requirements for utilization review programs.

3 AAC 28.930 specifies the applicability requirements for health care insurer grievance procedures.

3 AAC 28.932 establishes grievance reporting and grievance recordkeeping requirements.

3 AAC 28.934 establishes grievance review procedures.

3 AAC 28.936 establishes procedures for reviews of grievances involving an adverse determination.

3 AAC 28.938 establishes procedures for expedited reviews of grievances involving an adverse determination.

3 AAC 28.950 specifies the applicability requirements for external review of health care insurer coverage decisions.

3 AAC 28.952 establishes notice of right to external review requirements.

3 AAC 28.954 establishes procedures for requests for external review.

3 AAC 28.956 establishes procedures for an exhaustion of internal grievance process.

3 AAC 28.958 establishes procedures for standard external reviews.

3 AAC 28.960 establishes procedures for expedited external reviews.

3 AAC 28.962 establishes procedures for external reviews of experimental or investigational treatment adverse determinations.

3 AAC 28.964 establishes procedures for the declination of an external review assignment by an independent review organization.

3 AAC 28.966 provides for the binding nature of an external review decision.

3 AAC 28.968 provides for the term of an initial independent review organization registration period and establishes renewal requirements.

3 AAC 28.970 provides for the approval and registration of independent review organizations.

3 AAC 28.972 establishes procedures for the examination, suspension or revocation of an independent review organization's registration.

3 AAC 28.974 establishes minimum qualifications for independent review organizations.

3 AAC 28.976 provides for immunity for independent review organizations.

3 AAC 28.978 establishes external review reporting requirements.

3 AAC 28.980 requires health care insurers to pay the costs of an external review.

3 AAC 28.982 establishes disclosure requirements of external review procedures.

3 AAC 28.999 sets forth definitions for terms in 3 AAC 28.

Amendment to Chapter 31

3 AAC 31.060 is proposed to be changed to establish an independent review organization registration fee.

You may comment on the proposed regulation changes, including the potential costs to private persons of complying with the proposed changes, by submitting written comments to the Division of Insurance; Attention: Grey Mitchell; P.O. Box 110805; Juneau, AK 99811-0805; by                                                                                                                                                                                                                                                                              e-mail to grey.mitchell@alaska.gov; or by fax to (907) 465-3422. Comments may also be submitted through the Alaska Online Public Notice System at http://aws.state.ak.us/OnlinePublicNotices. All comments must be received no later than 5:00 p.m., October 19, 2017.

Oral or written comments also may be submitted at a hearing to be held on October 6, 2017 in Room 102 on the first floor of the Atwood Building, located at 550 West 7th Avenue, Anchorage, Alaska. The hearing will be held from 11:00 a.m. to 1:00 p.m. and might be extended to accommodate those present before 1:00 p.m. who did not have an opportunity to comment. If you are unable to attend the meeting in person and would like to participate by teleconference, please call 1-800-315-6338 and enter the access code 42070 followed by #.

You may submit written questions relevant to the proposed action to the Division of Insurance; Attention: Grey Mitchell; P.O. Box 110805, Juneau, AK 99811-0805 or by e-mail to grey.mitchell@alaska.gov. The questions must be received at least 10 days before the end of the public comment period. The division will aggregate its response to substantially similar questions and make the questions and responses available on the division's website at https://www.commerce.alaska.gov/web/ins/HearingsMeetingsandNotices.aspx and on the Alaska Online Public Notice System. The division may, but is not required to, answer written questions received after the 10-day cut-off date and before the end of the comment period.

If you are a person with a disability who needs a special accommodation in order to participate in the process, please contact Laura Watson at laura.watson@alaska.gov or (907) 465-2597 or TDD (907) 465-5437 no later than October 2, 2017 to ensure that any necessary accommodations can be provided.

A copy of the proposed regulation changes is available on the division's website at https://www.commerce.alaska.gov/web/ins/HearingsMeetingsandNotices.aspx, on the Alaska Online Public Notice System, by contacting Grey Mitchell at grey.mitchell@alaska.gov, or by calling (907) 269-7900 in Anchorage or (907) 465-2515 in Juneau.

After the public comment period ends, the Division of Insurance will either adopt the proposed regulation changes or other provisions dealing with the same subject, without further notice, or decide to take no action. The language of the final regulation may be different from that of the proposed regulation. YOU SHOULD COMMENT DURING THE TIME ALLOWED IF YOUR INTERESTS COULD BE AFFECTED. Written comments received are public records and are subject to public inspection.

Statutory Authority: AS 21.06.090; AS 21.07.005.
Statutes Being Implemented, Interpreted, or Made Specific: AS 21.07.005. 
Fiscal Information: The proposed regulation changes are not expected to require an increased appropriation.

DATE: August 30, 2017.

_________/ss/_____________________
Lori Wing-Heier
Director of Insurance


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Attachments, History, Details

Revision History

Created 9/1/2017 10:48:49 AM by cwagoner
Modified 9/1/2017 10:55:38 AM by cwagoner

Details

Department: Commerce, Community and Economic Development
Category: Regulations
Sub-Category: Notice of Proposed Regulations
Location(s): Statewide
Project/Regulation #: JU2017200563
 
Publish Date: 9/1/2017
Archive Date: 10/20/2017
 
Events/Deadlines: