Sec. 31.10.30.05. Timing and Notice of an Appeal Determination

A. An insurer shall give written or electronic notice that complies with the standards imposed by 29 CFR §2520.104b-1(c)(1)(i), (iii), and (iv), of an appeal determination to a covered individual within a reasonable period of time, but not later than 45 days after receipt of an appeal of an adverse benefit determination, unless the 45-day period is extended in accordance with this regulation.

B. Subject to §E of this regulation, the period of time within which an appeal determination shall be made begins at the time an appeal is received, without regard to whether all the information necessary to make an appeal determination accompanies the filing.

C. The initial 45-day time period under §A of this regulation may be extended for a period not to exceed 45 days if the insurer:

(1) Determines that the extension is necessary due to special circumstances; and

(2) Provides the notice required under §D of this regulation to the covered individual prior to the expiration of the initial 45-day period.

D. The notice of an extension under §C of this regulation shall be in writing and include:

(1) A description of the special circumstances requiring the extension of time; and

(2) The date by which the insurer plans to render a decision.

E. If the period of time within which an appeal determination is required to be made is extended under §C of this regulation due to a covered individual's failure to submit information necessary to decide the appeal, the period for making the appeal determination shall be tolled (temporarily suspended) from the date on which the notice of the extension is sent to the covered individual until the date on which the covered individual responds to the request for additional information.

F. The notice of an adverse appeal determination shall include:

(1) The specific reason or reasons for the adverse appeal determination;

(2) A reference to the specific policy provisions on which the adverse appeal determination is based;

(3) A statement that the covered individual is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the covered individual's claim for benefits; and

(4) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse appeal determination, either:

(a) The specific rule, guideline, protocol, or other similar criterion; or

(b) A statement that:

(i) An internal rule, guideline, protocol, or other similar criterion was relied on in making the adverse appeal determination; and

(ii) A copy of the rule, guideline, protocol, or other similar criterion will be provided on request free of charge to the covered individual; and

(5) The address, telephone number, and facsimile number of the Commissioner.

G. An insurer shall provide access to, and copies of, documents, records, and other information described in §F(3) and (4) of this regulation.