33-32-307. Grievance review procedures. (1) Except as specified in 33-32-309, a health insurance issuer shall use written procedures for receiving and resolving grievances from covered persons as provided in 33-32-308.

(2) (a) Whenever a health insurance issuer fails to adhere to the requirements of 33-32-308 or 33-32-309, as applicable, with respect to receiving and resolving grievances involving an adverse determination or waives the review of the grievance, the covered person is considered to have exhausted the provisions of this part and may take action under subsection (2)(b).

(b) (i) A covered person may file a request for external review in accordance with the procedures outlined in Title 33, chapter 32, part 4.

(ii) In addition to filing a request under subsection (2)(b)(i), a covered person is entitled to pursue any available remedies under state or federal law on the basis that the health insurance issuer failed to provide a reasonable internal claims and appeals process that would yield a decision on the merits of the claim.

(3) (a) The provisions of 33-32-308 or 33-32-309 may not be considered exhausted based on a de minimis violation that does not cause and is not likely to cause prejudice or harm to the covered person as long as the health insurance issuer demonstrates that the violation was for good cause or due to matters beyond the control of the health insurance issuer and that the violation occurred in the context of an ongoing, good faith exchange of information between the health insurance issuer and the covered person or, if applicable, the covered person's authorized representative.

(b) The exception provided in subsection (3)(a) does not apply if the violation is part of a pattern or a practice of violations by the health insurance issuer.

(4) A health insurance issuer shall file with the commissioner:

(a) a copy of the procedures required under subsection (1), including all forms used to process requests made pursuant to 33-32-308. Any subsequent material modifications to the documents must also be filed.

(b) as part of the annual report required by 33-32-306(7), a certificate of compliance stating that the health insurance issuer has established and maintains for each of its health plans a set of grievance procedures that fully comply with the provisions of this part; and

(c) a description of the grievance procedures required under this section, which must be included in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage provided to covered persons. The grievance procedure documents must include a statement of a covered person's right to contact the commissioner's office for assistance at any time. The statement must include the telephone number and address of the commissioner's office.

(5) The commissioner may disapprove a filing received in accordance with subsection (4) if the filing fails to comply with this part or applicable federal regulations.

History: En. Sec. 14, Ch. 428, L. 2015.