Revised Statutes of the State of New Hampshire §415-A:4-a

“Minimum standards for claim review; accident and health insurance under the insurance law”

A health insurer offering group health plans and employee benefit plans must establish written procedures to allow an enrollee to obtain a determination of claim and appeal a claim denial.

The procedures for determination of a claim must meet the following standards:

• The plan must maintain a toll-free telephone number to ensure that a representative of the plan is accessible to insureds, patients, and claimant’s representatives;
• Clinical review criteria used in making claim benefit determinations must be developed with input from health care professionals, updated at least biennially, developed in accordance with the standards of national accreditation entities, based on current, nationally accepted standards of medical practice, and evidence based; and
• The notification of a claim denial must be communicated in writing or by electronic means.

The determination of a claim involving urgent care must be made within 72 hours after receipt of the claim.

The determination of all other claims for preservice benefits must be made within 15 days after receipt of the claim.

The determination of a post service claim must be made within 30 days of the date of filing.

Any health insurance carrier that offers group health plans and employee benefit plans must file with the Department of Insurance a copy of its claim determination procedure, including all forms used, and a copy of the materials designed to inform its members of the requirements of the claim determination and grievance procedure and the responsibilities and rights of the members under the plan each year.

No fees or costs must be assessed against a claimant related to a request for claim benefit determination.