SB 410 - Adverse Determination Reviews Summary

• Establishes timeframes for health carriers to make benefit determinations: 15 calendar days for nonurgent prospective/concurrent reviews, 30 days for retrospective reviews, and 72 hours for urgent care requests, with limited extension options.

• Requires detailed written notice of adverse determinations including specific reasons for denial, applicable plan provisions, description of internal grievance procedures, and rights to external review and contact information for the Insurance Commissioner and Healthcare Advocate.

• Mandates that covered persons deemed to have exhausted internal grievance processes due to health carrier non-compliance may file external review requests regardless of claimed substantial compliance or de minimis errors.

• Establishes procedures for internal grievance reviews with timelines of 30 days for prospective/concurrent requests, 60 days for retrospective requests, and 72 hours for expedited reviews, requiring independent clinical peers and consideration of all submitted materials.

• Creates external review process with filing fees of $25 per request (capped at $75 annually per covered person), 45-day decision timeframes for standard reviews, and expedited reviews within 72 hours for urgent medical conditions or experimental treatment denials.