RI Gen L § 27-18.9-6(b)(2)

October 15, 2021 5:33 am | Published by

(2) Notification content shall:

(i) Be culturally and linguistically appropriate;

(ii) Provide details of a claim that is being denied to include date of service, provider, amount of claim, a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning as applicable;

(iii) Give specific reason or reasons for the adverse benefit determination;

(iv) Include the reference(s) to specific health benefit plan or review agent provisions, guideline, protocol, or criterion on which the adverse benefit determination is based;

(v) If the decision is based on medical necessity, clinical criteria or experimental treatment or similar exclusion or limit, then notice must include the scientific or clinical judgment for the adverse determination;

(vi) Provide information for the beneficiary as to how to obtain copies of any and all information relevant to the denied claim free of charge;

(vii) Describe the internal and external appeal processes, as applicable, to include all relevant review agency contacts and OHIC’s consumer assistance program information;

(viii) Clearly state timeline that the claimant has at least one hundred eighty (180) calendar days following the receipt of notification of an adverse benefit determination to file an appeal; and

(ix) Be written in a manner to convey clinical rationale in layperson terms when appropriate based on clinical condition and age and in keeping with federal and state laws and regulations.

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