1. (a) Except as specified under 3 AAC 28.938, a health care insurer shall use written procedures for receiving and resolving a grievance under 3 AAC 28.930 - 3 AAC 28.938.

2. (b) A covered person will be considered to have exhausted the provisions of 3 AAC 28.930 - 3 AAC 28.938 if a health care insurer fails to adhere to the requirements of 3 AAC 28.936 or 3 AAC 28.938 and may

   1. (1) file a request for external review under 3 AAC 28.950 - 3 AAC 28.982; and
   2. (2) pursue an available remedy under state or federal law on the basis that the health care insurer failed to provide a reasonable internal claims and appeals process that would yield a decision on the merits of the claim.

3. (c) Notwithstanding (b) of this section, a covered person is considered not to have exhausted the provisions of 3 AAC 28.930 - 3 AAC 28.938 if the failure of a health care insurer to adhere to the requirements of 3 AAC 28.936 or 3 AAC 28.938 is a de minimis violation that

   1. (1) does not cause, and is not likely to cause, prejudice or harm to the covered person;
   2. (2) the health care insurer demonstrates was for good cause or due to matters beyond the health care insurer's control;
   3. (3) occurred in the context of an ongoing, good-faith exchange of information between the health care insurer and the covered person or the covered person's authorized representative; and
   4. (4) is not a part of a pattern or practice of violations by the health care insurer.

4. (d) A covered person or the covered person's authorized representative may request a written explanation of the de minimis violation from a health care insurer. Not later than 10 days after receiving the request, the health care insurer shall

   1. (1) provide a written explanation of the alleged violation; and
   2. (2) the specific reasons for asserting that the violation is de minimis.
5. (e) A covered person or the covered person's authorized representative may resubmit and pursue a review of a grievance under 3 AAC 28.930 - 3 AAC 28.938 if an independent reviewer or superior court rejects the grievance involving an adverse determination for immediate review on the basis that the violation is a de minimis violation under (c) of this section.
6. (f) Not later than 10 days after receiving notice from an independent reviewer or a court of a rejection of a grievance due to a de minimis violation, a health care insurer shall provide to a covered person or the covered person's authorized representative notice of the opportunity to resubmit and, as appropriate, pursue a review of the grievance under 3 AAC 28.930 - 3 AAC 28.938. The time period for resubmitting a grievance under this subsection and (e) of this section begins to run when the covered person or the covered person's authorized representative receives notice of the opportunity to resubmit.

7. (g) A health care insurer shall file with the director

   1. (1) a copy of the grievance procedures required under this section, including all forms used to process requests under 3 AAC 28.936; and
   2. (2) subsequent material modifications to previously filed documents.
8. (h) The director may disapprove a filing received under (g) of this section that fails to comply with the provisions of 3 AAC 28.930 - 3 AAC 28.938.
9. (i) A health care insurer shall set out in, or attach to, a policy, certificate of coverage, membership booklet, outline of coverage, or other evidence of coverage provided to a covered person, a description of the grievance procedures required under 3 AAC 28.930 - 3 AAC 28.938. The description and other grievance procedure documents of the health care insurer must include a statement of a covered person's or the covered person's authorized representative's right to contact the director for assistance at any time. The statement must include the division's current mailing address, electronic mail address, and telephone number.

(Eff. 3/15/2018, Register 225)