Utilization Review Regulations Adopted

On January 14, 2021, the Division of Insurance adopted amended Regulation 4-2-17. This regulation requires carriers to adopt and implement reasonable standards for the prompt investigation of claims arising from health coverage plans; promptly provide a reasonable explanation of the basis in the health coverage plan in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement; and refrain from denying a claim without conducting a reasonable investigation based upon all available information.

The amendments allow dentists to evaluate first level reviews involving dental care and consult with an appropriate clinical peer or peers, and other non-substantive changes. The amendments are effective March 15, 2021.

Employers with plans regulated by the state should be aware of these amendments.

Regulation 4-2-17 »