Terms, conditions, and exclusions of the policy, other than the failure to meet the requirements to pay the claim. The Long-Term Care Insurance Independent Review Organizations. superintendent shall contract with qualified long-term care insurance independent review organizations. To be considered qualified, an organization must meet the following criteria: Have on staff, or contract with, a qualified and licensed health care professional in an appropriate field for determining an functional insured’s or cognitive impairment (e.g., physical therapy, occupational therapy, neurology, physical medicine and rehabilitation), to conduct the review. Neither it nor any of its licensed health care professionals may, in any manner, be related to or affiliated with a person or entity that previously provided medical care to the insured. Utilize a licensed health care professional who is not an employee of the insurer or related in any manner to the insured. Neither it nor its licensed health care professional who conducts the reviews may receive compensation of any type that is dependent on the outcome of the review. Provide a description of the fees it charges for external reviews of a care insurance adverse benefit determination. Such fees shall be reasonable and customary for the type of long-term care insurance adverse benefit determination under review. Provide the name of the medical director or health care professional responsible for the supervision and oversight of the external review procedure. Have on staff or contract with a licensed health care practitioner, who is qualified to certify that an individual is chronically ill for purposes of a qualified long-term care insurance contract. (Drafting Note: Although this section does not apply to contracts issued or issued for delivery in other states even if the insured becomes a resident of this state, insurers are encouraged to voluntarily adopt these standards for insureds who obtain long-term care services in this state. Nothing in this rule prohibits insurers from voluntarily complying with this section.)
Terms, conditions, and exclusions of the policy, other than the failure to meet the requirements to pay the claim. Long-Term Care Insurance Independent Review Organizations. The superintendent shall contract with qualified long-term care insurance independent review organizations. To be considered qualified, an organization must meet the following criteria: Have on staff, or contract with, a qualified and licensed health care professional in an appropriate field for determining an insured’s functional or cognitive impairment (e.g., physical therapy, occupational therapy, neurology, physical medicine and rehabilitation), to conduct the review. Neither it nor any of its licensed health care professionals may, in any manner, be related to or affiliated with a person or entity that previously provided medical care to the insured. Utilize a licensed health care professional who is not an employee of the insurer or related in any manner to the insured. Neither it nor its licensed health care professional who conducts the reviews may receive compensation of any type that is dependent on the outcome of the review. Provide a description of the fees it charges for external reviews of a care insurance adverse benefit determination. Such fees shall be reasonable and customary for the type of long-term care insurance adverse benefit determination under review. Provide the name of the medical director or health care professional responsible for the supervision and oversight of the external review procedure. Have on staff or contract with a licensed health care practitioner, who is qualified to certify that an individual is chronically ill for purposes of a qualified long-term care insurance contract. (Drafting Note: Although this section does not apply to contracts issued or issued for delivery in other states even if the insured becomes a resident of this state, insurers are encouraged to voluntarily adopt these standards for insureds who obtain long-term care services in this state. Nothing in this rule prohibits insurers from voluntarily complying with this section.)