Independent Health Care Appeals (IHCAP) Process Guidance

TRINIDAD NAVARRO COMMISSIONER [LOGO] STATE OF DELAWARE DEPARTMENT OF INSURANCE # DOMESTIC AND FOREIGN INSURERS BULLETIN NO. 111 TO: ALL HEALTH INSURERS AND THIRD PARTY ADMINISTRATORS RE: INDEPENDENT HEALTH CARE APPEALS (IHCAP) PROCESS GUIDANCE DATED: September 10, 2019 It has come to the Department's attention that some insurance carriers and/or third party administrators are not complying with the strict time limits for processing independent health care appeals as required under 18 Del.C. §§ 6416 and 6417, and 18 DE Admin. Code § 1301. Accordingly, the purpose of this bulletin is to provide guidance regarding these time limits. Delaware Code provides that an insured or the insured's authorized representative has up to four months from receipt of a carrier's adverse benefit determination to submit a request to the insurer for an independent review of the denial (in whole or in part) of a health insurance claim through the carrier's independent health care appeals process (IHCAP). Processing request for external appeal from an insured: Once the carrier receives an external appeal request from its insured, the carrier must submit the request to the Department for assignment to one of the Department's contracted independent review vendors in accordance with the following: - Within three business days from the date appellant requested access to IHCAP – this timeframe begins on the date the insured's external appeal request is initially received in the insurer's mailroom or from the date that is electronically stamped in the header of the facsimile containing the insured's request; - By using the updated designated form found on the Department's website at: https://insurance.delaware.gov/wp-content/uploads/sites/15/2019/05/petition-for-iuro-assignment-proposed.pdf. NOTE: This Bulletin is intended solely for informational purposes. It is not intended to set forth legal rights, duties, or privileges, nor is it intended to provide legal advice. Readers should consult applicable statutes and rules and contact the Delaware Department of Insurance if additional information is needed. ♦ INSURANCE.DELAWARE.GOV ♦ 1351 W. NORTH ST., SUITE 101, DOVER, DELAWARE 19904-2465 (302) 674-7300 DOVER ♦ (302) 739-5280 GEORGETOWN ♦ (302) 577-5280 WILMINGTON Responding to independent review decision: If the independent review vendor determines that the carrier's decision to deny a claim in whole or in part should be reversed, the carrier or its third party administrator must: - Pay the claim within 30 days of the date of that decision (see 18 DE Admin. Code § 903-4.0); and - Provide to the Department: o A copy of the dated letter in which the carrier notified the insured of the decision; o The amount of the claim to be paid by the carrier; o The amount remaining to be paid by the insured (if any); and o The check number and issue date. Any/all correspondence with the Department, including questions regarding this bulletin, should be submitted electronically to IURO@delaware.gov. This bulletin shall be effective immediately and shall remain in effect unless withdrawn or superseded by subsequent law, regulation or bulletin. Trinidad Navarro Trinidad Navarro Delaware Insurance Commissioner