Information on Internal Grievance Process

(1) The carrier or utilization review organization shall provide insureds with: (a) A clear, concise and complete written description of the carrier's internal grievance process. (b) A toll-free telephone number for assisting insureds in resolving such grievances and the consumer assistance toll-free number maintained by the Office of Patient Protection, and if applicable, the designated state consumer assistance program. (c) Notification about the availability of these resources. (2) A notice of adverse determination shall comply with applicable state and federal law, including applicable regulations and guidance issued by the Commissioner of Insurance. (3) The carrier or utilization review organization shall provide certain additional information to the insured or insured's authorized representative where, during the internal grievance process, the carrier or utilization review organization considers, generates, or relies upon new evidence or a new rationale for its decision to deny coverage which was not provided to the insured or insured's authorized representative with the adverse determination. (a) The carrier or utilization review organization shall provide the insured or insured's authorized representative, free of charge, with any new or additional evidence considered, relied upon, or generated by the carrier or utilization review organization (or at the direction of the carrier or utilization review organization) in connection with the grievance. During a non-expedited review, such evidence must be provided as soon as possible and sufficiently in advance of, and no fewer than seven days prior to, the date on which the carrier or utilization review organization is required to provide the notice of final adverse determination, to give the insured or insured's authorized representative a reasonable opportunity to respond prior to that date; and (b) Before the carrier or utilization review organization can issue a final adverse determination based on a new or additional rationale, the insured or insured's authorized representative must be provided, free of charge, with the rationale. During a non-expedited review, the rationale must be provided as soon as possible and sufficiently in advance of, and no fewer than seven days prior to, the date on which the carrier or utilization review organization is required to provide the notice of final adverse determination, to give the insured or insured's authorized representative a reasonable opportunity to respond prior to that date. (c) During an expedited internal review, the carrier or utilization review organization shall provide the insured or insured's authorized representative, free of charge, with any new or additional evidence referenced at 958 CMR 3.301(3)(a), or any new or additional rationale referenced at 958 CMR 3.301(3)(b), as soon as possible.