2013 Alaska Statutes
Title 21 - INSURANCE
Chapter 21.07 - PATIENT PROTECTIONS UNDER HEALTH CARE INSURANCE POLICIES
Sec. 21.07.020 Required contract provisions for health care insurance policy.
A health care insurance policy must contain
(1) a provision that preauthorization for a covered medical procedure on the basis of medical necessity may not be retroactively denied unless the preauthorization is based on materially incomplete or inaccurate information provided by or on behalf of the provider;
(2) a provision for emergency room services if any coverage is provided for treatment of a medical emergency;
(3) a provision that covered medical care services be reasonably available in the community in which a covered person resides or that, if referrals are required by the policy, adequate referrals outside the community be available if the medical care service is not available in the community;
(4) a provision that any utilization review decision
(A) must be made within 72 hours after receiving the request for preapproval for nonemergency situations; for emergency situations, utilization review decisions for care following emergency services must be made as soon as is practicable but in any event not later than 24 hours after receiving the request for preapproval or for coverage determination; and
(B) to deny, reduce, or terminate a health care benefit or to deny payment for a medical care service because that service is not medically necessary shall be made by an employee or agent of the health care insurer who is a licensed health care provider;
(5) a provision that provides for an internal appeal mechanism for a covered person who disagrees with a utilization review decision made by a health care insurer; except as provided under (6) of this section, this appeal mechanism must provide for a written decision
(A) from the health care insurer within 18 working days after the date written notice of an appeal is received; and
(B) on the appeal by an employee or agent of the health care insurer who holds the same professional license as the health care provider who is treating the covered person;
(6) a provision that provides for an internal appeal mechanism for a covered person who disagrees with a utilization review decision made by a health care insurer in any case in which delay would, in the written opinion of the treating provider, jeopardize the covered person's life or materially jeopardize the covered person's health; the health care insurer shall
(A) decide an appeal described in this paragraph within 72 hours after receiving the appeal; and
(B) provide for a written decision on the appeal by an employee or agent of the health care insurer who holds the same professional license as the health care provider who is treating the covered person;
(7) a provision that discloses the existence of the right to an external appeal of a utilization review decision made by a health care insurer; the external appeal shall be conducted in accordance with AS 21.07.050;
(8) a provision that discloses covered benefits, optional supplemental benefits, and benefits relating to and restrictions on nonparticipating provider services;
(9) a provision that describes the preapproval requirements and whether clinical trials or experimental or investigational treatment are covered;
(10) a provision describing a mechanism for assignment of benefits for health care providers and payment of benefits;
(11) a provision describing availability of prescription medications or a formulary guide, and whether medications not listed are excluded; if a formulary guide is made available, the guide must be updated annually; and
(12) a provision describing available translation or interpreter services, including audiotape or braille information.
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