2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 120 - Health Insurance Organization or Issuer Grievance Procedure (§§ 9391 — 9400) › § 9397 - First level reviews of grievances involving an adverse determination

(a) Within one hundred eighty (180) days after the receipt of a notice of an adverse determination, a covered person or enrollee, or his/her authorized representative, may file a grievance with the health insurance organization or issuer requesting a first level review of the adverse determination.
(b) The health insurance organization or issuer shall provide the covered person or enrollee with the name, address, and telephone number of a person or organization designated to coordinate the first level review on behalf of the health insurance organization or issuer.
(c)
(1)
(A) If the grievance arises from an adverse determination involving utilization review, the health insurance organization or issuer shall designate one or more clinical peers of the same or similar specialty as would typically manage the case being reviewed to review the adverse determination. The designated clinical peer(s) shall not have been involved in the initial adverse determination.
(B) The health insurance organization or issuer shall ensure that, if more than one clinical peer is involved in the review, they have appropriate expertise.
(2) In conducting a review under this section, the reviewer(s) shall take into consideration all comments, documents, records, and other information regarding the request for services submitted by the covered person or enrollee, or his/her authorized representative, without regard to whether the information was submitted or considered in making the initial adverse determination.
(d)
(1)
(A) The covered person or enrollee or, if applicable, his/her representative shall be entitled to:
(i) Submit written comments, documents, records, and other material related to the grievance under review, and
(ii) receive from the health insurance organization or issuer, upon request and free of charge, access to and copies of all documents, records, and other information relevant to the grievance.
(B) For purposes of paragraph (A)(ii) of this clause, a document, record, or other information shall be considered relevant to a grievance if the document, record, or other information:
(i) Was relied upon in making the benefit determination;
(ii) was submitted, considered, or generated in the course of making the adverse determination, without regard to whether the document, record, or other information was relied upon in making the benefit determination;
(iii) demonstrates that, in making the benefit determination, the health insurance organization or issuer consistently applied the same administrative procedures and safeguards with respect to the covered person or enrollee as other similarly situated covered persons or enrollees, or
(iv) constitutes a statement of policy or guidance with respect to the health plan concerning the denied healthcare service or treatment for the covered person or enrollee's diagnosis, without regard to whether the statement or guidance was relied upon in making the initial adverse determination.
(2) The health insurance organization or issuer shall make the provisions of clause (1) of this subsection known to the covered person or enrollees or, if applicable, his/her authorized representative, within three (3) working days after the date of receipt of the grievance.
(e) For purposes of calculating the time periods within which a determination is required to be made and notice provided under subsection (f) of this section, the time period shall begin on the date the grievance is filed with the health insurance organization or issuer, without regard to whether all of the information necessary to make the determination accompanies such filing. If the health insurance organization or issuer understands that the grievance does not include all the necessary information to make a determination, it shall clearly indicate the covered person or enrollee or, if applicable, his/her authorized representative, the reasons for which it cannot process such grievance and the additional documents or information that the covered person or enrollee must provide.
(f)
(1) Health insurance organizations or issuers shall notify and issue a decision in writing, or electronically if the covered person or enrollee or, if applicable, his/her authorized representative, has agreed to be thus notified, within the timeframes provided in clause (2) or (3) of this subsection.
(2) With respect to a grievance requesting a first level review of an adverse determination involving a prospective review request, the health insurance organization or issuer shall notify and issue a decision within a reasonable period of time that is appropriate given the covered person or enrollee's medical condition, but not later than fifteen (15) calendar days after the receipt of the grievance.
(3) With respect to a grievance requesting a first level review of an adverse determination involving a retrospective review request, the health insurance organization or issuer shall notify and issue a decision within a reasonable period of time, but not later than thirty (30) calendar days after the receipt of the grievance.
(g) The determination issued pursuant to subsection (f) shall state in a manner that is comprehensible to the covered person or enrollee or, if applicable, his/her authorized representative:
(1) The titles and qualifying credentials of the person or persons participating in the first level review process (the reviewers).
(2) A statement of the reviewers' understanding of the covered person or enrollee's grievance.
(3) The reviewers' decision in clear terms and the contract basis or medical rationale for the covered person or enrollee or, if applicable, his/her authorized representative, to respond to the health insurance organization or issuer's position.
(4) The evidence or documentation used as the basis for the decision.
(5) In the event that the health insurance organization or issuer's first level review decision results in an adverse determination, the following shall also be included:
(A) The specific reasons for the adverse determination;
(B) the reference to the specific health plan provisions on which the determination is based;
(C) a statement that the covered person or enrollee is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant, as the term “relevant” is defined in subsection (d)(1)(B) of this section;
(D) if the health insurance organization or issuer relied upon an internal rule, guideline, protocol, or other similar criterion to make the final adverse determination, a copy of such rule, guideline, protocol, or other similar criterion in which the final adverse determination was based shall be provided, upon request and free of charge, to the covered person or enrollee or, if applicable, his/her authorized representative;
(E) if the final adverse determination is based on a medical necessity, experimental or investigational treatment, or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the determination or a statement that an explanation shall be provided, upon request and free of charge, to the covered person or enrollee or, if applicable, his/her authorized representative, and
(F) if applicable, instructions for requesting:
(i) A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the final adverse determination, as provided in paragraph (D) of this clause, and
(ii) a written statement of the scientific or clinical rationale for the determination, as provided in paragraph (E) of this clause.
(6) If applicable, a statement indicating:
(A) A description of the process to obtain an additional voluntary review if the covered person or enrollee wishes to request a voluntary review pursuant to § 9399 of this title;
(B) the written procedures governing the voluntary review, including any required timeframe for the review;
(C) a description of the procedures for obtaining an independent external review, pursuant to this Code's chapter on Health Insurance Organization or Issuer External Review, if the covered person or enrollee decides not to file for an additional voluntary review, and
(D) the covered person or enrollee's right to bring a civil action in a court of competent jurisdiction;
(7) If applicable, and stressing its voluntary nature, the following statement: “You and your health plan may have other voluntary alternative dispute resolution options, such as mediation or arbitration. One way to find out what may be available is to contact the Commissioner of Insurance”.
(8) Notice of the covered person or enrollee’s right to contact the Office of the Insurance Commissioner and the Office of the Patient’s Advocate for assistance with respect to any claim, grievance or appeal at any time, including the telephone number and address of the Office of the Insurance Commissioner and the Office of the Patient’s Advocate.
History —Aug. 29, 2011, No. 194, § 22.070, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 27, eff. 30 days after July 10, 2013.