Prohibits setting minimum dollar amount for claim subject to adverse determination to be eligible to pursue the applicable review process of an appeal of the adverse action.
Clarifies that a member who received an adverse determination, rather than an individual who is denied a claim or a claimed service, may pursue applicable review.
Allows insurer, in group plans and grandfathered individual plans, to offer voluntary internal appeal as additional level of review after determination of initial appeal.
Requires insurer to issue written determination with explanation of the decision.
States that insurer's failure to comply constitutes exhaustion of internal levels of review and permits insurer to waive interview appeal process in its entirety.
Clarifies information that must be included in packet sent to member for appeal.
Provides that if issue is appropriateness of care, insurer must perform initial appeal to be decided by a physician; any additional information to be free of cost to member.
Expedited Medical Review
Clarifies that adverse determination recipient may pursue expedited medical review if treating provider states delay likely to cause significant negative change in condition.
Increases time to send determination notice to 72 hours but requires that it include basis of decision, criteria used, clinical reasons, and the rationale for determination.
Provides that if issue is appropriateness of care, insurer must perform initial appeal to be decided by a physician; any additional information to be free of cost to member.
Adds definition of providers for purposes of appeal of adverse determination.
Miscellaneous Provisions
Sets forth procedures for initial appeal, voluntary internal appeal, and external independent review; sets recordkeeping requirements for at least 3 years.
Includes a definition for the terms final internal adverse determination, grandfathered individual plan, health care setting, and internal level of review and rescission.
Legislative History
On Jan. 22, 2024, bill introduced in House; on Feb. 29, 2024, bill passed House.
On Mar 7, 2024, bill introduced in Senate; on Apr. 10, 2024, bill passed Senate.
Effectiveness
Upon governor approval or veto override, HB 2599 will be effective Dec. 1, 2024.
Apr 2024 AZ LEG Governor's Approval
On Apr. 23, 2024, AZ LEG reported Governor approved bill HB 2599, enrolled Ch. 178.
