A health carrier shall issue utilization review and benefit determinations in a timely manner pursuant to the requirements of §§ 58-17H-27 to 58-17H-32, inclusive, and §§ 58-17H-40 to 58-17H-48, inclusive. A health carrier shall have a process to ensure that utilization reviewers apply clinical review criteria in conducting utilization review consistently.
If a health carrier fails to strictly adhere to the requirements of §§ 58-17H-27 to 58-17H-32, inclusive, and §§ 58-17H-40 to 58-17H-48, inclusive, with respect to making utilization review and benefit determinations of a benefit request or claim, the covered person shall be deemed to have exhausted the provisions of chapters 58-17G and 58-17H, and may take action regardless of whether the health carrier asserts that the carrier substantially complied with the requirements of §§ 58-17H-27 to 58-17H-32, inclusive, and §§ 58-17H-40 to 58-17H-48, inclusive, as applicable, or that any error it committed was de minimus.
Any covered person may file a request for external review in accordance with rules promulgated by the director. In addition to the external review rights a covered person is entitled to pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal claims and appeals process that would yield a decision on the merits of the claim.