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) › § 9430 - Procedures for expedited utilization review and benefit determinations

(a)
(1) Health insurance organizations or issuers shall establish written procedures for notifying covered persons or enrollees of expedited utilization review and benefit determinations with respect to urgent care requests.
(2)
(A) As part of the procedures required under clause (1) of this subsection, a health insurance organization or issuer shall provide that, if the covered person or enrollee fails to meet its filing procedures with regard to an urgent care request, the health insurance organization or issuer shall notify the covered person or enrollee of such failure and provide the proper procedures to be followed for filing a request.
(B) The notice of the failure in the filing of an urgent care request:
(i) Shall be provided to the covered person or enrollee, as soon as possible, but in no event later than twenty-four (24) hours after receipt of the request, and
(ii) may be provided orally or, if requested by the covered person or enrollee, in writing.
(b)
(1)
(A) For an urgent care request, the health insurance organization or issuer shall notify the covered person or enrollee of its determination with respect to the request, whether or not the determination is an adverse determination, as soon as possible, taking into account the medical condition of the covered person or enrollee, but in no event later than twenty-fours (24) hours after the date of the receipt of the request by the health insurance organization or issuer, unless the covered person or enrollee has failed to provide sufficient information for the health insurance organization or issuer to determine whether the benefits requested are covered benefits or payable under the health plan.
(B) In the case of an adverse determination, the health insurance organization or issuer shall provide notice of such adverse determination in accordance with subsection (e) of this section.
(2)
(A) If the covered person or enrollee has failed to provide sufficient information for the health insurance organization or issuer to make a determination, the health insurance organization or issuer shall provide notice of such failure to the covered person or enrollee, whether orally or, if requested by the covered person or enrollee, in writing, and shall indicate the specified information needed, as soon as possible, but in no event later than twenty-four (24) hours after the date of receipt of the request.
(B) The health insurance organization or issuer shall provide the covered person or enrollee a reasonable period of time to submit the additional necessary information, but in no event less than forty-eight (48) hours after the date notice of such failure was provided.
(C) The health insurance organization or issuer shall notify the covered person or enrollee its determination with respect to an urgent care request as soon as possible, but in no event less than forty-eight (48) hours after the earlier of the following:
(i) The health insurance organization or issuer's receipt of the requested specified additional information, or
(ii) the end of the period provided for the covered person or enrollee to submit the requested specified information.
(D) If the covered person or enrollee fails to submit the requested specified information before the end of the period granted, the health insurance organization or issuer may deny the certification of the requested benefit.
(E) In the case of an adverse determination, the health insurance organization or issuer shall provide notice of such adverse determination in accordance with subsection (e) of this section.
(c)
(1) For concurrent review urgent care requests, involving a request by the covered person or enrollee to extend the course of treatment beyond the initial period of time or the number of treatments prescribed, if the request is made at least twenty-four (24) hours prior to the expiration of the prescribed period of time or number of treatments, the health insurance organization or issuer shall make a determination with respect to the request and notify the covered person or enrollee of the determination, as soon as possible, taking into account the covered person or enrollee's medical condition but in no event more than twenty-four (24) hours after the date of the receipt of the request.
(d) For purposes of calculating the time periods within which the health insurance organization or issuer is required to make a determination under subsections (b) and (c) 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 procedures established pursuant to § 9427 of this title for filing a request without regard to whether all of the information necessary to make the determination accompanies the filing.
(e)
(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) A description of the health insurance organization or issuer's expedited review procedures established pursuant to § 9400 of this title, including any time limits applicable to those procedures.
(G) 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.
(H) 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.
(I) 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 § 24.100 on Aug. 23, 2012, No. 203, § 5, eff. 90 days after Aug. 23, 2012.