Sec. 31.10.29.03. Exhaustion of Internal Appeal Process

A. Except as provided in §B of this regulation, the carrier's internal appeal process shall be exhausted before filing a complaint with the Commissioner under this chapter.

B. In a case involving a prospective denial, a member, a member’s representative, or a health care provider filing a complaint on behalf of a member may file a complaint with the Commissioner without first filing an appeal with a carrier and receiving a final decision on the appeal if the member, the member’s representative, or the health care provider gives sufficient information and supporting documentation in the complaint that demonstrates an urgent medical condition exists as defined under this chapter.

C. In a case involving a retrospective denial, an urgent medical condition is not deemed to exist to allow a member, a member’s representative, or a health care provider on behalf of a member to file to a complaint without first exhausting the internal appeal process of a carrier.