Section Ins 2703.01 - Applicability and Scope(a) Except as provided in (b) below, the external review requirements set forth in this rule shall apply to all health carriers that provide or perform utilization review. Any health carrier that makes an adverse determination concerning a covered person shall be considered to be performing utilization review.(b) The external review requirements set forth in this part shall not apply to determinations relating to: (1) Long-term care insurance, as defined by RSA 415-D;(2) Coverage under a plan through Medicare, Medicaid, the state Children's Health Insurance Program, Title XXI of the Social Security Act, including services provided under these programs but through a contracted health carrier;(3) Health care services provided to inmates by the department of corrections;(4) The federal employees health benefits program;(5) Coverage issued under chapter 55 of title 10 of the United States Code regarding medical and dental care for members of the Armed Forces;(6) Coverage issued as supplemental to liability insurance, workers' compensation or similar insurance, automobile medical-payment insurance, or any insurance under which benefits are payable with or without regard to fault, whether written on a group blanket or individual basis; or(7) Health care services provided pursuant to a health plan not regulated by the state, such as self-funded plans administered by an administrative services organization or third-party administrator.(c) The external review procedures set forth in this rule shall not be utilized to adjudicate claims or allegations of health care provider malpractice, professional negligence, or other professional fault against participating providers or medical directors.N.H. Admin. Code § Ins 2703.01
#7539, eff 8-1-01; ss by 8862, eff 5-1-07 (from 2703.02)
Amended by Volume XXXV Number 36, Filed September 10, 2015, Proposed by #10918, Effective 9/1/2015, Expires9/1/2025.