Revised Statutes of the State of New Hampshire §420-J:5

“Grievance procedures under the insurance law”

Every health insurer must establish a written procedure that allows enrollees to have a reasonable opportunity to appeal a claim denial to the health insurer and have a fair review of the claim denial.

Full and fair review shall require that:

• The persons reviewing the grievance shall not be the same person or persons making the initial determination, and shall not be subordinate to or the supervisor of the person making the initial determination;
• For medical necessity appeals at least one person reviewing the appeal is a practitioner in the same or similar specialty who typically treats the medical condition, performs the procedure, or provides the treatment at issue in the appeal;
• The claimant shall have at least 180 days following receipt of a notification of a claim denial to appeal;
• The claimant shall have an opportunity to submit written comments, documents, records, and other information relating to the claim without regard to whether those documents or materials were considered in making the initial determination;
• The claimant shall be provided upon request, and without charge, reasonable access to, and copies of all documents, records, and other information relevant to or considered in making the initial adverse claim determination; and
• The review shall be a de novo proceeding and shall consider all information, documents, or other material submitted in connection with the appeal without regard to whether the information was considered in making the denial.

In the case of nonexpediated appeal related to a pre-service claim or post-service claim, a carrier must make a determination within 30 days.

In the case of nonexpediated appeal related to an urgent care claim, a carrier must make a determination with 72 hours.

The carrier must provide a claimant with a written determination of the appeal.