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

“Appeal procedure under the insurance law”

Every health insurer that offers group health insurance or employee benefit plans must maintain 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.  The written procedure must be filed with the insurance department.

Full and fair review of a claim requires that:

• The person(s) reviewing the grievance must not be the same person or persons making the initial determination, must not be subordinate to or the supervisor of the person making the initial determination, and must act as a fiduciary;
• The person reviewing the grievance on a first or second level appeal must have appropriate medical and professional expertise and credentials to competently render a determination on appeal;
• The claimant or claimant's representative must have at least 180 days following receipt of a notification of an adverse claim determination to appeal;
• The claimant or claimant's representative must 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 or claimant's representative must 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 must consider all information, documents, or other material submitted in connection with the appeal without regard to whether the information was considered in making the claim denial.

In the case of nonexpediated appeal of a pre-service claim or a post-service claim, the determination on appeal must be made within 30 days after receipt by the carrier of the claimant’s appeal.

In the case of an expedited appeal related to an urgent care claim, a carrier must make a determination within 72 hours after the appeal is filed.