2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 122 - Utilization Review and Benefit Determination (§§ 9421 — 9434) › § 9429 - Procedures for standard utilization review and benefit determinations

(a) A health insurance organization or issuer shall maintain written procedures for making standard utilization review and benefit determinations on requests for benefits submitted by covered persons or enrollees and for notifying its determinations within the specified time frames required under this section.
(b)
(1)
(A)
(i) For prospective review determinations, a health insurance organization or issuer shall make the determination and notify the covered person or enrollee of the determination, whether the issuer certifies the provision of the benefit or not, within a reasonable period of time appropriate to the covered person or enrollee's medical condition, but in no event later than fifteen (15) days after the date the health issuer receives the request.
(ii) Whenever the determination is an adverse determination, the health insurance organization or issuer shall make the notification of the adverse determination in accordance with subsection (f) of this section.
(B) The time period for making a determination and notifying the covered person or enrollee of the determination may be extended one time by the health insurance organization or issuer for up to fifteen (15) days, provided the health insurance organization or issuer meets the following requirements:
(i) Determines that an extension is necessary due to matters beyond the health insurance organization or issuer's control, and
(ii) notifies the covered person or enrollee prior to the expiration of the initial fifteen (15)-day time period, of the circumstances requiring the extension of time and the date by which the determination is expected to be made.
(C) If the extension is necessary due to the failure of the covered person or enrollee to submit information necessary for the health insurance organization or issuer to reach a determination on the request, the notice of extension shall meet the following requirements:
(i) Specifically describe the required information necessary to complete the request, and
(ii) give the covered person or enrollee at least forty- five (45) days from the date of receipt of the notice to provide the specified information.
(2)
(A) Whenever the health insurance organization or issuer receives a prospective review request that fails to meet the health insurance organization or issuer's procedure to file requests for benefits, it shall notify the covered person or enrollee of such failure and provide in the notice information on the proper procedures to be followed for filing a request.
(B)
(i) The notice of the failure shall be provided, as soon as possible, but in no event later than five (5) days following the date of the failure.
(ii) The health insurance organization or issuer may provide the notice orally or, if so requested by the covered person or enrollee, in writing.
(C)
(1) For concurrent review determinations, if a health insurance organization or issuer has previously certified an ongoing course of treatment to be provided over a period of time or number of treatments, the following rules shall apply:
(A) Any reduction or termination by the health insurance organization or issuer during the course of treatment before the end of the previously certified period or number of treatments, other than by health plan amendment or termination of the health plan, shall constitute an adverse determination, and
(B) The health insurance organization or issuer shall notify the covered person or enrollee of the adverse determination in accordance with subsection (f) of this section in advance of the reduction or termination to allow the covered person or enrollee to file a grievance pursuant to §§ 9391–9400 of this title and obtain a determination with respect to such grievance before the benefit is reduced or terminated.
(2) The healthcare service or treatment that is the subject of the adverse determination shall be continued until the health insurance organization or issuer notify the covered person or enrollee of the determination made with respect to a grievance filed pursuant to §§ 9391–9400 of this title.
(d)
(1)
(A) For retrospective review determinations, a health insurance organization or issuer shall make the determination within a reasonable period of time, but in no event later than thirty (30) days after the date of receiving the request.
(B) If the determination is an adverse determination, the health insurance organization or issuer shall provide notice of the adverse determination in accordance with subsection (f) of this section.
(2)
(A) The time period for making a determination and notifying the covered person or enrollee may be extended one time by the health insurance organization or issuer for up to fifteen (15) days, provided the health insurance organization or issuer meets the following requirements:
(i) Determines that an extension is necessary due to matters beyond the health insurance organization or issuer's control, and
(ii) notifies the covered person or enrollee prior to the expiration of the initial thirty (30)-day time period, of the circumstances requiring the extension of time and the date by which a determination is expected to be made.
(B) If the extension is necessary due to the failure of the covered person or enrollee to submit information necessary for the health insurance organization or issuer to reach a determination on the request, the notice of extension shall:
(i) Specifically describe the required information necessary to complete the request, and
(ii) give the covered person or enrollee at least forty- five (45) days from the date of receipt of the notice for the covered person or enrollee to provide the specified additional information.
(e)
(1) For purposes of calculating the time period within which the health insurance organization or issuer is required to make a determination under subsections (b) and (d) of this section, the time period shall begin on the date the request is filed with the health insurance organization or issuer in accordance with the procedures established pursuant to § 9427 of this title without regard to whether all of the information necessary to make the determination accompanies the filing.
(2)
(A) If the time period for making the determination is extended due to the covered person or enrollee's failure to submit the information necessary to make the determination, the time period for making the determination shall be tolled from the date on which the health insurance organization or issuer sends the notification of the extension to the covered person or enrollee or until the earlier of:
(i) The date on which the covered person or enrollee responds to the request for additional information, or
(ii) the date on which the specified information should have been submitted.
(B) If the covered person or enrollee fails to submit the information before the end of the period of the extension, the health insurance organization or issuer may deny the certification of the requested benefit.
(f)
(1) If as a result of a utilization review and benefit determination process, the health insurance organization or issuer provides a notification of an adverse determination such notification shall, in a manner calculated to be understood by the covered person or enrollee, set forth:
(A) Information sufficient to identify the benefit request or claim involved, including, if applicable, the date of service; the provider; the claim amount; the diagnosis code and its meaning; and the treatment code and its meaning;
(B) the specific reasons for the adverse determination, including the denial code and its meaning, as well as a description of the standard, if any, that was used in denying such benefit request or claim;
(C) reference to the specific plan provisions on which the determination is based;
(D) a description of any additional material or information necessary for the covered person or enrollee to perfect the benefit request, including an explanation of why the material or information is necessary to perfect the request;
(E) a description of the health insurance organization or issuer's grievance procedures established pursuant to §§ 9391–9400 of this title, including any time limits applicable to those procedures;
(F) if the health insurance organization or issuer relied upon an internal rule, guideline, protocol or other similar criterion to make the adverse determination, a copy of the rule, guideline, protocol or other similar criterion shall be provided free of charge to the covered person or enrollee;
(G) if the adverse determination is based on a medical necessity for the service or treatment or the experimental or investigational nature thereof or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the determination and for applying the terms of the health plan to the covered person or enrollee's medical circumstances shall be included with the notification, and
(H) a statement of the right of the covered person or enrollee, as appropriate, to contact the Office of the Commissioner or the Office of the Patient's Advocate at any time for assistance or, to file a civil suit in a court of competent jurisdiction upon completion of the health insurance organization or issuer's grievance procedure process. The statement shall include contact information for the Office of the Commissioner or the Office of the Patient's Advocate.
(2) A health insurance organization or issuer shall provide the notice required under this section in a culturally and linguistically appropriate manner as required under federal law.
History —Aug. 29, 2011, No. 194, added as § 24.090 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.