North Carolina Licensed Insurers Offering PPO Benefit Plans

TO: North Carolina Licensed HMOs North Carolina Licensed Insurers Offering PPO Benefit Plans

FROM: Cheryl Allen-Bivens, Market Analyst Donna Tucker, Market Analyst Market Regulation Division

RE: NCGS 58-3-191 (“Managed care reporting and disclosure requirements.”)

The Market Regulation Division of the North Carolina Department of Insurance has posted the 2013 managed care annual filing documents for reporting data year 2012 results. Pursuant to NCGS 58-3-191, completed filings are due on or before May 1, 2013 by 5:00 p.m. EDT. These files can be downloaded from the Department’s website: (http://www.ncdoi.com/MR/MR_MC_Annual_Requirments.aspx). If an Insurer believes their company should be exempt from an annual filing, a request for exemption must be received by the Department on or before the deadline of March 15, 2013 by 5:00 p.m. EDT. A request must be submitted on the Insurer’s letterhead with the reason(s) for exemption and signed by an officer of the company. The request must be sent to the attention of the company’s assigned Market Analyst either Cheryl Allen-Bivens via email [email protected] or Donna Tucker via email [email protected] as indicated in your Call Letter previously submitted to you via email. An exemption request is only valid for the specified data year. An exemption request must be submitted for each applicable data year.

North Carolina domestic Carriers and foreign Carriers that have and are utilizing their North Carolina domestic HMO or PPO affiliate should use the file labeled “Domestic2012InstructionsFullService.doc” or “Domestic2012InstructionsSingleService.doc”. Foreign Carriers that do not have and/or utilize a North Carolina domestic HMO or PPO affiliate must use the file labeled “Foreign2012InstructionsFullService.doc” or “Foreign2012InstructionsSingleService.doc”.

If you are a Carrier that has never submitted an Annual Filing, or if you are an existing Carrier that added/ replaced an Intermediary or added a new product line (i.e. Dental or Vision), you must complete the supplemental form labeled “InitialFilers&NewIntermediaryForm2012.doc”.

The filing must be submitted via email to [email protected] and must be received no later than May 1, 2013 by 5:00 p.m. EDT. It is important to note that late, incomplete and/or non- compliant filings may be subject to a monetary penalty as outlined in NCGS 58-2-70. You must ensure that you are completing the applicable 2012 document versions, and that you read the instructions for each item carefully to ensure all necessary information is provided. Feel free to contact the company’s assigned Market Analyst either Cheryl Allen-Bivens at (919) 807-6891([email protected]) or Donna Tucker, at (919) 807-6897([email protected]), as indicated in your Call Letter previously submitted to you via email, if you have any questions or concerns.

If the Department's Market Regulation Division has performed a market conduct examination of your company within the past year, we strongly encourage you to discuss and review this filing with your company's exam coordinator, to ensure that company information submitted in this filing is consistent with company information furnished during the examination.

1 Market Examination ANNUAL MANAGED CARE DATA FILING (NCGS 58-3-191) Throughout these materials, the terms “Plan,” “Carrier” and “Insurer” refer to the licensed HMO or Insurer responsible for the filing.

ON WHICH PRODUCTS, MEMBERSHIP AND FILING PERIOD SHOULD REPORTING BE BASED? This filing (NCGS 58-3-191), due on 5/1/2013 by 5:00 pm EDT, is required for licensed HMOs and licensed insurers offering PPO benefit plans in NC. 1. Plan’s reporting must be based on commercial-insured individual and group membership covered under master contracts sitused in North Carolina; also, commercial-insured must include insureds covered under group trust master contracts sitused out-of-state but marketed to North Carolina residents. Includes insureds living or working in North Carolina. Reference NCGS 58-3-1 and 58-3-150. Exclude membership covered under self-funded (non-risk), federally insured, and Medicare or Medicaid plans. 2. Insurers that offer both a full-service and single-service PPO product must submit a separate filing for each. 3. All references to “filing period” shall be defined as January 1, 2012 through December 31, 2012.

FILES NEEDED: NAME TYPE CONTENTS Domestic2012InstructionsFullService.doc MS Word *General Instructions *Annual Filing Checklist *Overall Plan Attestation *Compliance Certification: Grievance and/or External Review Procedures *Compliance Certification: Delegated Grievance and/or External Review Procedures *Compliance Certification: Utilization Review and/or External Review *Compliance Certification: Delegated Utilization Review and/or Delegated External Review *Compliance Certification: Intermediary Arrangements *Compliance Certification: Provider Availability and Accessibility *Compliance Certification: Delegated Provider Availability and Accessibility

InitialFilers&NewIntermediaryForm2012.doc MS Word *Supplemental Checklist ONLY needed if new filer or existing filer who added/replaced an Intermediary or added a new product line

2012PlanDataFullService.xls MS Excel *Grids for Plan Data

2012DelegatedDataFullService.xls MS Excel *Grids for Data from Delegated Entities (including Netwok Intermediaries, Pharmacy Benefit Managers.)

*The Domestic 2012 Instructions document MUST be sent as MS WORD or .pdf files. *The Plan Data and Delegated Data files MUST be sent as MS Excel files.

Link to NORTH CAROLINA GENERAL STATUTES

Link to NORTH CAROLINA ADMINISTRATIVE RULES

WHERE SHOULD THE COMPLETED FILING BE SENT? Completed filings must be submitted via email to [email protected] no later than 5/1/2013 by 5:00 pm EDT.

WHAT IF QUESTIONS ARISE? General questions about NC filing requirements: Cheryl Allen-Bivens, Market Analyst, Market Regulation Division, (919) 807-6891 or [email protected] Donna Tucker, Market Analyst, Market Regulation Division, (919) 807-6897 or [email protected] ---

NC Dept. of Insurance 2 Market Regulation Division – Domestic Carriers Full Service January 2013 MARKET REGULATION DIVISION C1. Annual Filing Checklist Plan ITEM ITEM INSTRUCTIONS / PLAN COMMENTS Check-Off ITEM NAME APPLIES TO: LOCATION PERIOD # http://www.ncdoi.com/MR/MR_MC_Annual_Requirments.aspx Included Data Year Submit this Checklist with the Plan's check-offs. C1 Annual Filing Checklist Plan only C1. Annual Filing Checklist 2012 Submit with all requested information. Two Company officers’ Included Data Year signatures/dates are required. C2 Overall Plan Attestation Plan only C2. Overall Attestation 2012

Submit one Grievance and/or External Review Procedures Compliance Certification if the Plan internally processed any member Grievances C3a.Compliance Certification: Included Compliance during any part of the specified data year. Grievance Procedures C3a Certification: Grievance Plan only Data Year C3b.Compliance Certification: C3b Procedures and External 2012 N/A External Review related to Explain if N/A: Review Grievances

Compliance Submit one Delegated Grievance and/or External Review Procedures Certification: Delegated Compliance Certification for each delegated entity that processed Grievance Procedures Grievances filed by Plan members during any part of the specified data and/or External Review year. List the Delegated Entity(s): C4a.Compliance Certification: Explain if N/A: Delegated Grievance Included C4a Entity: Plan only Procedures Data Year C4b C4b.Compliance Certification: 2012 N/A Entity: Delegated External Review related to Grievances Entity:

Entity:

Submit one Utilization Review and/or External Review Compliance Certification if Plan conducted any Utilization Review and/or External Review internally on services provided to Plan members during any part of the specified data year. Compliance C5a.Compliance Certification: Included C5a Certification: Utilization Plan only Utilization Review Data Year Explain if N/A: C5b Review and/or External C5b.Compliance Certification: 2012 N/A Review External Review

NC Dept. of Insurance 3 Market Regulation Division – Domestic Carriers Full Service January 2013 Plan ITEM ITEM INSTRUCTIONS / PLAN COMMENTS Check-Off ITEM NAME APPLIES TO: LOCATION PERIOD # http://www.ncdoi.com/MR/MR_MC_Annual_Requirments.aspx Submit one Delegated Utilization Review and/or External Review Compliance Compliance Certification for each delegated entity to which the Plan Certification: Delegated delegated Utilization Review and/or External Review for any part of the Utilization Review specified data year. and/or Delegated External Review C6a.Compliance Certification: Included List the Delegated Entity(s): Explain if N/A: C6a Plan only Delegated Utilization Review Data Year C6b Entity: C6b.Compliance Certification: 2012 N/A Delegated External Review Entity:

Entity:

Submit one Intermediary Arrangements Compliance Certification for each Compliance Intermediary used during any part of the specified data year. Certification: Included Intermediary C7. Compliance Certification: Data Year C7 Plan only Arrangements including Intermediary Arrangements 2012 Explain if N/A: N/A Pharmacy Benefit Managers

Submit one Provider Availability and Accessibility Compliance Certification for the Plan and each Intermediary if the Plan sets the targets Compliance Plan only for any part of the specified data year. Included Certification: Provider C8. Compliance Certification: (Use when targets Data Year C8 Availability and Provider Availability and are set by the 2012 Accessibility Accessibility Explain if N/A: N/A Plan.)

Compliance Submit one Delegated Provider Availability and Accessibility Compliance Certification if the Intermediary set the targets and monitored provider Certification: Delegated availability and accessibility during any part of the specified data year. Provider Availability and Accessibility Plan only Included List the Delegated Entity(s): (Use when targets Explain if N/A: C9. Compliance Certification: are set by the Data Year C9 Entity: Delegated Provider Availability Intermediary or 2012 N/A and Accessibility Entity: Delegated Entity.) Entity:

Entity:

NC Dept. of Insurance 4 Market Regulation Division – Domestic Carriers Full Service January 2013 Plan ITEM ITEM INSTRUCTIONS / PLAN COMMENTS Check-Off ITEM NAME APPLIES TO: LOCATION PERIOD # http://www.ncdoi.com/MR/MR_MC_Annual_Requirments.aspx

Included Enrollment/ Plan: Grid D1, As of D1 Disenrollment Summary Plan only 2012PlanDataFullService.xls 12/31/12 N/A for 2012

Included Enrollment by County @ Plan: Grid D2, As of D2 Plan only N/A 12/31/12 2012PlanDataFullService.xls 12/31/12

Plan Plan: Grid D3, Grievances, by Reason Included 2012PlanDataFullService.xls (excluding Grievances and/or Data Year D3 related to Utilization 2012 Delegated Entities: Grid D3, N/A Review decisions) Delegated 2012DelegatedDataFullService.xls Entity(s)

Plan Plan: Grid D4, Included Utilization Review 2012PlanDataFullService.xls and/or Data Year D4 Decisions, by Review 2012 Type Delegated Entities: Grid D4, N/A Delegated 2012DelegatedDataFullService.xls Entity(s)

Plan Plan: Grid D5, Included Utilization Review 2012PlanDataFullService.xls and/or Data Year D5 Decisions, by Service 2012 Type Delegated Entities: Grid D5, N/A Delegated 2012DelegatedDataFullService.xls Entity(s)

Plan: Grid D6, Plan 2012PlanDataFullService.xls Included Providers by County @ As of D6 and/or 12/31/12 Intermediaries: Grid D6, 12/31/12 N/A 2012DelegatedDataFullService.xls Intermediary(s)

Plan: Grid D7, Plan 2012PlanDataFullService.xls Included Unique Providers on As of D7 and/or Network Intermediaries: Grid D7, 12/31/12 N/A 2012DelegatedDataFullService.xls Intermediary(s)

Plan: Grid D8, Plan Providers Leaving 2012PlanDataFullService.xls Included Network During 2012, Data Year D8 and/or by Reason and Provider Intermediaries: Grid D8, 2012 N/A Type 2012DelegatedDataFullService.xls Intermediay(s)

Plan: Grid D9, Plan 2012PlanDataFullService.xls Included Providers Joining Data Year D9 Network During 2012, and/or Intermediaries: Grid D9, 2012 by Provider Type N/A 2012DelegatedDataFullService.xls Intermediary(s)

Plan: Grid D10, Network Density: Plan 2012PlanDataFullService.xls Included Plan/Intermediary Data Year D10 Targets, by Provider and/or Intermediaries: Grid D10, 2012 Type and Geographic N/A 2012DelegatedDataFullService.xls Area Intermediary(s)

Network Density: Plan Plan: Grid D11, Actual Included 2012PlanDataFullService.xls Plan/Intermediary As of D11 and/or Performance, by 12/31/12 Intermediaries: Grid D11, N/ A Provider Type and Intermediary(s) 2012DelegatedDataFullService.xls Geographic Area

Plan: Grid D12, Driving Distance: Plan 2012PlanDataFullService.xls Included Plan/Intermediary Data Year D12 Targets, by Provider and/or Intermediaries: Grid D12, 2012 Type and Geographic N/A 2012DelegatedDataFullService.xls Area Intermediary(s)

Driving Distance: Plan: Grid D13, Plan Actual 2012PlanDataFullService.xls Included Plan/Intermediary As of D13 and/or Performance, by Intermediaries: Grid D13, 12/31/12 N/A Provider Type and 2012DelegatedDataFullService.xls Intermediary(s) Geographic Area

Appointment Wait Plan Plan: Grid D14, Times: Included 2012PlanDataFullService.xls Plan/Intermediary Data Year D14 and/or Targets, by Provider 2012 Intermediaries: Grid D14, N/A Type and Appointment Intermediary(s) 2012DelegatedDataFullService.xls Type

Appointment Wait Plan Plan: Grid D15, Times: Actual Included 2012PlanDataFullService.xls Plan/Intermediary Data Year D15 and/or Performance, by 2012 Intermediaries: Grid D15, N/A Provider Type and Intermediary(s) 2012DelegatedDataFullService.xls Appointment Type

Plan Plan: Grid D16, Percentage of Providers Included 2012PlanDataFullService.xls Under Each As of D16 and/or Compensation Model, by 12/31/12 Intermediaries: Grid D16, N/A Provider Type Intermediary(s) 2012DelegatedDataFullService.xls

N/A if the compensation model is fee-for-service without withhold or bonus. Plan Plan: Grid D17, Included Range of Withholds and 2012PlanDataFullService.xls As of D17 Bonuses, by and/or 12/31/12 N/A Compensation Model Intermediaries: Grid D17, Intermediary(s) 2012DelegatedDataFullService.xls

List of Plan’s Delegated Included Entities and Network Plan: Grid D18, Data Year D18 Intermediaries including Plan 2012PlanDataFullService.xls 2012 N/A Pharmacy Benefit Managers

NC Dept. of Insurance 7 Market Regulation Division – Domestic Carriers Full Service January 2013 Plan ITEM ITEM INSTRUCTIONS / PLAN COMMENTS Check-Off ITEM NAME APPLIES TO: LOCATION PERIOD # http://www.ncdoi.com/MR/MR_MC_Annual_Requirments.aspx Refer to the Department’s closure letter with the attachment of the final Outstanding issues from Plan findings from the previous data year. Included the previous data year N/A being addressed and any If previous filing N/A N/A N/A requested information was closed other being submitted than “Accepted”.

New Filers or Submit one form for each new Initial Operation Filing or new/replacing Existing Filers Intermediary Filing. Included who added or InitialFilers&NewIntermediaryForm Data Year N/A Supplemental Checklist replaced an 2012 2012 N/A Intermediary or added a new product line

NC Dept. of Insurance 8 Market Regulation Division – Domestic Carriers Full Service January 2013 MARKET REGULATION DIVISION C2. Overall Attestation (Required From All Plans Submitting a Filing. Plans that are under common ownership must submit a separate executed Attestation for each company.)

We hereby attest that we have reviewed the entire Annual Filing, and that the information being submitted for the period of January 1, 2012 through December 31, 2012 is true and complete.

The filing must be submitted electronically to the Department‘s mailbox at [email protected] on or before the deadline of May 1, 2013 by 5:00 p.m. EDT, or the next business day if May 1st falls on a Saturday, Sunday or holiday. It is important to note that late, incomplete and/or non-compliant filings may be subject to a monetary penalty as outlined in NCGS 58-2- 70.

Late filings will require a written explanation on the company’s letterhead signed/dated by the Company’s President at time of submission.

IMPORTANT NOTE: If the previous data year’s filing was closed as “Accepted with Issues” or “Non- compliant”, the Insurer must make sure to address the issues outlined in the Department’s closure letter and submit any requested information. Unresolved/Unanswered issues, failing to implement corrective action or compliance issues impacting North Carolina insureds may result in a market inquiry, market conduct examination and/or administrative penalty.

Name (Printed Name) Name (Printed Name)

Title (Company Officer) Title (Company Officer)

Signature Date Signature Date

Company Name

PRIMARY CONTACT INFORMATION

NC Dept. of Insurance 9 Market Regulation Division – Domestic Carriers Full Service January 2013

Name of Person Submitting the Filing (Printed) Title

Street Address City State Zip

Mailing Address City State Zip

( ) ( ) Direct Phone Number Toll Free Phone Number including extension

( ) Fax Number

E-Mail Address

PLEASE PROVIDE A BACKUP CONTACT, OR IF THE PERSON SUBMITTING THE FILING IS A CONSULTANT, A COMPANY CONTACT MUST BE PROVIDED.

Name of Person (Printed) Title

Street Address City State Zip

Mailing Address City State Zip

( ) ( ) Direct Phone Number Toll Free Phone Number including extension

( ) Fax Number

E-Mail Address

NC Dept. of Insurance 10 Market Regulation Division – Domestic Carriers Full Service January 2013 MARKET REGULATION DIVISION C3a. Compliance Certification: Grievance Procedures

In accordance with NCGS 58-50-62 (“Insurer grievance procedures”), (“Insurer”), duly licensed and authorized to do business in the State of North Carolina, certifies to the Commissioner of the North Carolina Department of Insurance that its Grievance procedures are compliant with the Statutes listed and referenced below (except to the extent of exceptions noted in Section II of this certification). Note: The actual documentation will be required at the Market Regulation Division’s next scheduled Market Conduct Examination of the Insurer or at the discretion of the Department.

I. Applicable Statutes

NCGS 58-50-62(b) Availability of Grievance Process. – Every insurer shall have a grievance process whereby a covered person may voluntarily request a review of any decision, policy, or action of the insurer that affects that covered person. A decision rendered solely on the basis that the health benefit plan does not provide benefits for the health care service in question is not subject to the insurer’s grievance procedures, if the exclusion of the specific service requested is clearly stated in the certificate of coverage. The grievance process may provide for an immediate informal consideration by the insurer of a grievance. If the insurer does not have a procedure for informal consideration or if an informal consideration does not resolve the grievance, the grievance process shall provide for first- and second-level reviews of grievances. Appeal of a noncertification that has been reviewed under G.S. 58-50-61 shall be reviewed as a second- level grievance under this section.

NCGS 58-50-62(b)(1) Informal Consideration of Grievances. If the insurer provides procedures for informal consideration of grievances, the procedures shall be in writing, and the following requirements apply: (1) If the grievance concerns a clinical issue and the informal consideration decision is not in favor of the covered person, the insurer shall treat the request as a request for a first-level grievance review, except that the requirements of subdivision (e)(1) of this section apply on the day the decision is made or on the tenth business day after receipt of the request for informal consideration, whichever is sooner; (2) If the grievance concerns a nonclinical issue and the informal consideration decision is not in favor of the covered person, the insurer shall issue a written decision that includes the information set forth in subsection (c) of this section; or (3) If the insurer is unable to render an informal consideration decision within 10 business days after receipt of the grievance, the insurer shall treat the request as a request for a first-level grievance review, except that the requirements of subdivision (e)(1) of this section apply beginning on the day the insurer determines an informal consideration decision cannot be made before the tenth business day after receipt of the grievance.

NCGS 58-50-62(c) Grievance Procedures. – Every insurer shall have written procedures for receiving and resolving grievances from covered persons. A description of the grievance procedures shall be set forth in or attached to the certificate of coverage and member handbook provided to covered persons. The description shall include a statement informing the covered person that the grievance procedures are voluntary and shall also inform the covered person about the availability of the Commissioner's office for assistance, including the telephone number and address of the office.

NC Dept. of Insurance 11 Market Regulation Division – Domestic Carriers Full Service January 2013 The description shall also inform the covered person about the availability of assistance from the Managed Care Patient Assistance Program, including the telephone number and address of the Program.

NCGS 58-50-62(d) Maintenance of Records. – Every insurer shall maintain records of each grievance received and the insurer's review of each grievance, as well as documentation sufficient to demonstrate compliance with this section. The maintenance of these records, including electronic reproduction and storage, shall be governed by rules adopted by the Commissioner that apply to insurers. The insurer shall retain these records for five years or until the Commissioner has adopted a final report of a general examination that contains a review of these records for that calendar year, whichever is later.

NCGS 58-50-62(e) First-Level Grievance Review. – A covered person or a covered person’s provider acting on the covered person's behalf may submit a grievance. (1) The insurer does not have to allow a covered person to attend the first-level grievance review. A covered person may submit written material. Except as provided in subdivision (3) of this subsection, within three business days after receiving a grievance, the insurer shall provide the covered person with the name, address, and telephone number of the coordinator and information on how to submit written material. (2) An insurer shall issue a written decision, in clear terms, to the covered person and, if applicable, to the covered person's provider, within 30 days after receiving a grievance. The person or persons reviewing the grievance shall not be the same person or persons who initially handled the matter that is the subject of the grievance and, if the issue is a clinical one, at least one of whom shall be a medical doctor with appropriate expertise to evaluate the matter. Except as provided in subdivision (3) of this subsection, if the decision is not in favor of the covered person, the written decision issued in a first-level grievance review shall contain: a. The professional qualifications and licensure of the person or persons reviewing the grievance. b. A statement of the reviewers' understanding of the grievance. c. The reviewers' decision in clear terms and the contractual basis or medical rationale in sufficient detail for the covered person to respond further to the insurer's position. d. A reference to the evidence or documentation used as the basis for the decision. e. A statement advising the covered person of his or her right to request a second-level grievance review and a description of the procedure for submitting a second-level grievance under this section. f. Notice of the availability of assistance from the Managed Care Patient Assistance Program, including the telephone number and address of the Program. (3) For grievances concerning the quality of care delivered by the covered person’s provider, the insurer shall acknowledge the grievance within 10 business days. The acknowledgement shall advise the covered person that (i) the insurer will refer the grievance to its quality assurance committee for review and consideration or any appropriate action against the provider and (ii) State law does not allow for a second-level grievance review for grievances concerning quality of care.

NCGS 58-50-62(f) Second-Level Grievance Review. – An insurer shall establish a second-level grievance review process for covered persons who are dissatisfied with the first-level grievance review decision or a Utilization Review appeal decision. A covered person or the covered person’s provider acting on the covered person’s behalf may submit a second-level grievance. (1) An insurer shall, within 10 business days after receiving a request for a second-level grievance review, make known to the covered person: a. The name, address, and telephone number of a person designated to coordinate the grievance review for the insurer.

NC Dept. of Insurance 12 Market Regulation Division – Domestic Carriers Full Service January 2013 b. A statement of a covered person's rights, which include the right to request and receive from an insurer all information relevant to the case; attend the second-level grievance review; present his or her case to the review panel; submit supporting materials before and at the review meeting; ask questions of any member of the review panel; and be assisted or represented by a person of his or her choice, which person may be without limitation to: a provider, family member, employer representative, or attorney. If the covered person chooses to be represented by an attorney, the insurer may also be represented by an attorney. c. The availability of assistance from the Managed Care Patient Assistance Program, including the telephone number and address of the Program. (2) An insurer shall convene a second-level grievance review panel for each request. The panel shall comprise persons who were not previously involved in any matter giving rise to the second-level grievance, are not employees of the insurer or URO, and do not have a financial interest in the outcome of the review. A person who was previously involved in the matter may appear before the panel to present information or answer questions. All of the persons reviewing a second-level grievance involving a noncertification or a clinical issue shall be providers who have appropriate expertise, including at least one clinical peer. Provided, however, an insurer that uses a clinical peer on an appeal of a noncertification under G.S. 58-50- 61 or on a first-level grievance review panel under this section may use one of the insurer's employees on the second-level grievance review panel in the same matter if the second-level grievance review panel comprises three or more persons.

NCGS 58-50-62(g) Second-Level Grievance Review Procedures. – An insurer's procedures for conducting a second-level grievance review shall include: (1) The review panel shall schedule and hold a review meeting within 45 days after receiving a request for a second-level review. (2) The covered person shall be notified in writing at least 15 days before the review meeting date. (3) The covered person's right to a full review shall not be conditioned on the covered person’s appearance at the review meeting.

NCGS 58-50-62(h) Second-Level Grievance Review Decisions. – An insurer shall issue a written decision to the covered person and, if applicable, to the covered person's provider, within seven business days after completing the review meeting. The decision shall include: (1) The professional qualifications and licensure of the members of the review panel. (2) A statement of the review panel's understanding of the nature of the grievance and all pertinent facts. (3) The review panel's recommendation to the insurer and the rationale behind that recommendation. (4) A description of or reference to the evidence or documentation considered by the review panel in making the recommendation. (5) In the review of a noncertification or other clinical matter, a written statement of the clinical rationale, including the clinical review criteria, that was used by the review panel to make the recommendation. (6) The rationale for the insurer's decision if it differs from the review panel's recommendation. (7) A statement that the decision is the insurer's final determination in the matter. In cases where the review concerned a noncertification and the insurer’s decision on the second-level grievance review is to uphold its initial noncertification, a statement advising the covered person of his or her right to request an external review and a description of the procedure for submitting a request for external review to the Commissioner of Insurance. (8) Notice of the availability of the Commissioner's office for assistance, including the telephone number and address of the Commissioner's office.

NC Dept. of Insurance 13 Market Regulation Division – Domestic Carriers Full Service January 2013 (9) Notice of the availability of assistance from the Managed Care Patient Assistance Program, including the telephone number and address of the Program.

NCGS 58-50-62(i) Expedited Second-Level Procedures. – An expedited second-level review shall be made available where medically justified as provided in G.S. 58-50-61(l), whether or not the initial review was expedited. The provisions of subsections (f), (g), and (h) of this section apply to this subsection except for the following timetable: When a covered person is eligible for an expedited second-level review, the insurer shall conduct the review proceeding and communicate its decision within four days after receiving all necessary information. The review meeting may take place by way of a telephone conference call or through the exchange of written information.

NCGS 58-50-62(j) – No insurer shall discriminate against any provider based on any action taken by the provider under this section or G.S. 58-50-61 on behalf of a covered person.

NCGS 58-50-62(k) Violation. – A violation of this section subjects an insurer to G.S. 58-2-70. (1997-519, s. 4.2.)

NC Dept. of Insurance 14 Market Regulation Division – Domestic Carriers Full Service January 2013 MARKET REGULATION DIVISION C3b. Compliance Certification: External Review related to Grievances

Pursuant to NCGS 58-3-191 (“Managed Care Reporting and Disclosure Requirements”) and NCGS 58-50-77, 58-50-79, 58-50-80 and 58-50-82 (“External Review”), (“Insurer”), duly licensed and authorized to do business in the State of North Carolina, certifies to the Commissioner of the North Carolina Department of Insurance that its External Review program is compliant with the Statutes listed and referenced below. Note: The actual documentation will be required at the Market Regulation Division’s next scheduled Market Conduct Examination of the Insurer or at the discretion of the Department.

NCGS 58 - 50 - 77 Notice of right to external review. (a) An insurer shall notify the covered person in writing of the covered person's right to request an external review and include the appropriate statements and information set forth in this section at the time the insurer sends written notice of: (1) A noncertification decision under G.S. 58-50-61; (2) An appeal decision under G.S. 58-50-61 upholding a noncertification; and (3) A second-level grievance review decision under G.S. 58-50-62 upholding the original noncertification. (b) The insurer shall include in the notice required under subsection (a) of this section for a notice related to a noncertification decision under G.S. 58-50-61, a statement informing the covered person that if the covered person has a medical condition where the time frame for completion of an expedited review of an appeal decision involving a noncertification decision under G.S. 58-50-61 would reasonably be expected to seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, then the covered person may file a request for an expedited external review under G.S. 58-50-82 at the same time the covered person files a request for an expedited review of an appeal involving a noncertification decision under G.S. 58-50-61, but that the Commissioner will determine whether the covered person shall be required to complete the expedited review of the grievance before conducting the expedited external review. (c) The insurer shall include in the notice required under subsection (a) of this section for a notice related to an appeal decision under G.S. 58-50-61, a statement informing the covered person that: (1) If the covered person has a medical condition where the time frame for completion of an expedited review of a grievance involving an appeal decision under G.S. 58-50-61 would reasonably be expected to seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, the covered person may file a request for an expedited external review under G.S. 58-50-82 at the same time the covered person files a request for an expedited review of a grievance involving an appeal decision under G.S. 58-50-62, but that the Commissioner will determine whether the covered person shall be required to complete the expedited review of the grievance before conducting the expedited external review. (2) If the covered person has not received a written decision from the insurer within 60 days after the date the covered person files the second- level grievance with the insurer pursuant to G.S. 58-50-62 and the covered person has not requested or agreed to a delay, the covered person may file a request for external review under G.S. 58-50-80 and shall be considered to have exhausted the insurer's internal grievance process for purposes of G.S. 58-50-79.

NC Dept. of Insurance 15 Market Regulation Division – Domestic Carriers Full Service January 2013 (d) The insurer shall include in the notice required under subsection (a) of this section for a notice related to a final second-level grievance review decision under G.S. 58-50-62, a statement informing the covered person that: (1) If the covered person has a medical condition where the time frame for completion of a standard external review under G.S. 58-50-80 would reasonably be expected to seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, the covered person may file a request for an expedited external review under G.S. 58-50-82; or (2) If the second-level grievance review decision concerns an admission, availability of care, continued stay, or health care service for which the covered person received emergency services but has not been discharged from a facility, the covered person may request an expedited external review under G.S. 58-50-82. (e) In addition to the information to be provided under this section, the insurer shall include a copy of the description of both the standard and expedited external review procedures the insurer is required to provide under G.S. 58-50-93, including the provisions in the external review procedures that give the covered person the opportunity to submit additional information. (2001-446, s. 4.5.)

NCGS 58 - 50 - 79 Exhaustion of internal grievance process. (a) Except as provided in G.S. 58-50-82, a request for an external review under G.S. 58-50-80 or G.S. 58-50-82 shall not be made until the covered person has exhausted the insurer's internal appeal and grievance processes under G.S. 58-50-61 and G.S. 58-50-62. (b) A covered person shall be considered to have exhausted the insurer's internal grievance process for purposes of this section, if the covered person: (1) Has filed a second-level grievance involving a noncertification appeal decision under G.S. 58-50-61 and G.S. 58-50-62, and (2) Except to the extent the covered person requested or agreed to a delay, has not received a written decision on the grievance from the insurer within 60 days since the date the covered person filed the grievance with the insurer. (c) Notwithstanding subsection (b) of this section, a covered person may not make a request for an external review of a noncertification involving a retrospective review determination made under G.S. 58-50-61 until the covered person has exhausted the insurer's internal grievance process. (d) A request for an external review of a noncertification may be made before the covered person has exhausted the insurer's internal grievance and appeal procedures under G.S. 58-50-61 and G.S. 58-50-62 whenever the insurer agrees to waive the exhaustion requirement. If the requirement to exhaust the insurer's internal grievance procedures is waived, the covered person may file a request in writing for a standard external review as set forth in G.S. 58-50-80 or may make a request for an expedited external review as set forth in G.S. 58-50-82. In addition, the insurer may choose to eliminate the second-level grievance review under G.S. 58-50-62. In such case, the covered person may file a request in writing for a standard external review under G.S. 58-50-80 or may make a request for an expedited external review as set forth in G.S. 58-50-82 within 60 days after receiving notice of an appeal decision upholding a noncertification. (2001-446, s. 4.5.)

NCGS 58 - 50 - 80 Standard external review. (e) Failure by the insurer or its designee utilization review organization to provide the documents and information within the time specified in this subsection shall not delay the conduct of the external review.

However, if the insurer or its utilization review organization fails to provide the documents and information within the time specified in subdivision (b)(4) of this section, the assigned organization may terminate the external review and make a decision to reverse the noncertification NC Dept. of Insurance 16 Market Regulation Division – Domestic Carriers Full Service January 2013 appeal decision or the second-level grievance review decision. Within one business day of making the decision under this subsection, the organization shall notify the covered person, the insurer, and the Commissioner. (g) Upon receipt of the information required to be forwarded under subsection (f) of this section, the insurer may reconsider its noncertification appeal decision or second-level grievance review decision that is the subject of the external review. Reconsideration by the insurer of its noncertification appeal decision or second-level grievance review decision under this subsection shall not delay or terminate the external review. The external review shall be terminated if the insurer decides, upon completion of its reconsideration, to reverse its noncertification appeal decision or second-level grievance review decision and provide coverage or payment for the requested health care service that is the subject of the noncertification appeal decision or second-level grievance review decision. (h) Upon making the decision to reverse its noncertification appeal decision or second-level grievance review decision under subsection (g) of this section, the insurer shall notify the covered person, the organization, and the Commissioner in writing of its decision. The organization shall terminate the external review upon receipt of the notice from the insurer sent under this subsection. (l) Upon receipt of a notice of a decision under subsection (k) of this section reversing the noncertification appeal decision or second-level grievance review decision, the insurer shall within three business days reverse the noncertification appeal decision or second-level grievance review decision that was the subject of the review and shall provide coverage or payment for the requested health care service or supply that was the subject of the noncertification appeal decision or second-level grievance review decision. In the event the covered person is no longer enrolled in the health benefit plan when the insurer receives notice of a decision under subsection (k) of this section reversing the noncertification appeal decision or second-level grievance review decision, the insurer that made the noncertification appeal decision or second-level grievance review decision shall be responsible under this section only for the costs of those services or supplies the covered person received or would have received prior to disenrollment if the service had not been denied when first requested.

NCGS 58 - 50 - 82 Expedited external review. (c) As soon as possible, but within the same business day of receiving notice under subdivision (b)(2) of this section that the request has been assigned to a review organization, the insurer or its designee utilization review organization shall provide or transmit all documents and information considered in making the noncertification appeal decision or the second-level grievance review decision to the assigned review organization electronically or by telephone or facsimile or any other available expeditious method. A copy of the same information shall be sent by the same means or other expeditious means to the covered person or the covered person's representative who made the request for expedited external review. (f) If the notice provided under subsection (e) of this section was not in writing, within two days after the date of providing that notice, the assigned organization shall provide written confirmation of the decision to the covered person, the covered person's provider who performed or requested the service, the insurer, and the Commissioner and include the information set forth in G.S. 58-50-80(m).

Upon receipt of the notice of a decision under subsection (e) of this section that reverses the noncertification, noncertification appeal decision, or second-level grievance review decision, the insurer shall within one day reverse the noncertification, noncertification appeal decision, or second-level grievance review decision that was the subject of the review and shall provide coverage or payment for the requested health care service or supply that was the subject of the noncertification, noncertification appeal decision, or second-level grievance review decision. NC Dept. of Insurance 17 Market Regulation Division – Domestic Carriers Full Service January 2013 II. Monitoring Activities IMPORTANT NOTE: Answer the following questions applicable to Data Year 2012.

To demonstrate compliance with NCGS 58-3-191 and NCGS 58-50-62, Insurers with their own Grievance procedures must provide requested information within the text boxes below. Do not attach any additional documentation.

NC Dept. of Insurance 18 Market Regulation Division – Domestic Carriers Full Service January 2013 To demonstrate compliance with NCGS 58-3-191 and NCGS 58-50-77, NCGS 58-50-79, NCGS 58-50-80 and NCGS 58-50-82, Insurers with their own External Review programs must provide requested information within the text boxes below. Do not attach any additional documentation.

Check all type(s) of Grievances the Plan conducts on services provided to NC insureds: Informal Consideration 1st Level 2nd Level External Review

Check all type(s) of Grievances notifications developed and mailed by the Plan to NC insureds: Informal Consideration 1st Level 2nd Level External Review

Question 1: Identify each version of the Insurer’s Grievance Program - Policies & Procedures (P&Ps) including related form/template letters effective during the specified data year.

Answer 1:

Name of Insurer’s P&Ps, including any identification number/revision date: Who from the Insurer (i.e. Board of Directors, Committee or Officer) approved the P&Ps? (Must provide names and titles): Date Insurer approved the P&Ps: Effective Date of the P&Ps:

Question 2: Does the Grievance Program – Policies & Procedures (P&Ps) include mental health/chemical dependency and/or pharmacy benefit programs? If not, be sure to separately identify each of these policies.

Answer 2:

Question 3: When did the Insurer complete its most recent review of its own Grievance program - Policies & Procedures (P&Ps)? (Must specify month/year)

Answer 3:

Question 4: When does the Insurer anticipate conducting its next review of its own Grievance program - Policies & Procedures (P&Ps)? (Must specify month/year)

Answer 4:

Question 5: When did the Insurer complete its most recent review of its Grievance related form/template letters as referenced in NCGS 58-50-62, NCGS 58-50-77, 58-50-79, 58-50-80 and 58- 50-82? (Must specify month/year)

Answer 5:

NC Dept. of Insurance 19 Market Regulation Division – Domestic Carriers Full Service January 2013 Question 6: When did the Insurer complete its most recent audit sampling of actual case correspondence as referenced in NCGS 58-50-62, NCGS 58-50-77, 58-50-79, 58-50-80 and 58-50- 82? (Must specify month/year)

Answer 6:

Question 7: Specify the number of cases reviewed. (Applicable to Question/Answer #6)

Answer 7:

Question 8: What was the Company’s rationale in determining the number of cases reviewed? (Applicable to Question/Answer #7)

Answer 8:

Question 9: Were all the case correspondence compliant (language and time requirements) with State law and did they include External Review Rights when required? If not explain any deficiencies found, along with corrective actions taken and/or planned.

Answer 9:

Question 10: Identify areas of non-compliance identified in reviewing its own Grievance Program – Policies & Procedures (P&Ps) including the related form/template letters, along with corrective actions taken and/or planned.

Answer 10:

NC Dept. of Insurance 20 Market Regulation Division – Domestic Carriers Full Service January 2013 MARKET REGULATION DIVISION C4a. Compliance Certification: Delegated Grievance Procedures

In accordance with NCGS 58-50-62 (“Insurer grievance procedures”), (“Insurer”), duly licensed and authorized to do business in the State of North Carolina, hereby provides notification that (“Delegated Entity”) processes Grievances on Insurer’s behalf. Insurer certifies to the Commissioner of the North Carolina Department of Insurance that the Delegated Entity’s Grievance procedures, and the Insurer’s oversight/monitoring of those procedures, are compliant with the Statutes listed and referenced below (except to the extent of exceptions noted in Section II of this certification). Note: The actual documentation will be required at the Market Regulation Division’s next scheduled Market Conduct Examination of the Insurer or at the discretion of the Department.

NCGS 58-50-62(b) Availability of Grievance Process. – Every insurer shall have a grievance process whereby a covered person may voluntarily request a review of any decision, policy, or action of the insurer that affects that covered person. A decision rendered solely on the basis that the health benefit plan does not provide benefits for the health care service in question is not subject to the insurer’s grievance procedures, if the exclusion of the specific service requested is clearly stated in the certificate of coverage. The grievance process may provide for an immediate informal consideration by the insurer of a grievance. If the insurer does not have a procedure for informal consideration or if an informal consideration does not resolve the grievance, the grievance process shall provide for first- and second-level reviews of grievances. Appeal of a noncertification that has been reviewed under G.S. 58-50-61 shall be reviewed as a second- level grievance under this section.

NCGS 58-50-62(b)(1) Informal Consideration of Grievances. If the insurer provides procedures for informal consideration of grievances, the procedures shall be in writing, and the following requirements apply: (1) If the grievance concerns a clinical issue and the informal consideration decision is not in favor of the covered person, the insurer shall treat the request as a request for a first-level grievance review, except that the requirements of subdivision (e)(1) of this section apply on the day the decision is made or on the tenth business day after receipt of the request for informal consideration, whichever is sooner; (2) If the grievance concerns a nonclinical issue and the informal consideration decision is not in favor of the covered person, the insurer shall issue a written decision that includes the information set forth in subsection (c) of this section; or (3) If the insurer is unable to render an informal consideration decision within 10 business days after receipt of the grievance, the insurer shall treat the request as a request for a first-level grievance review, except that the requirements of subdivision (e)(1) of this section apply beginning on the day the insurer determines an informal consideration decision cannot be made before the tenth business day after receipt of the grievance.

NC Dept. of Insurance 21 Market Regulation Division – Domestic Carriers Full Service January 2013 NCGS 58-50-62(c) Grievance Procedures. – Every insurer shall have written procedures for receiving and resolving grievances from covered persons. A description of the grievance procedures shall be set forth in or attached to the certificate of coverage and member handbook provided to covered persons. The description shall include a statement informing the covered person that the grievance procedures are voluntary and shall also inform the covered person about the availability of the Commissioner's office for assistance, including the telephone number and address of the office. The description shall also inform the covered person about the availability of assistance from the Managed Care Patient Assistance Program, including the telephone number and address of the Program.

NCGS 58-50-62(d) Maintenance of Records. – Every insurer shall maintain records of each grievance received and the insurer's review of each grievance, as well as documentation sufficient to demonstrate compliance with this section. The maintenance of these records, including electronic reproduction and storage, shall be governed by rules adopted by the Commissioner that apply to insurers. The insurer shall retain these records for five years or until the Commissioner has adopted a final report of a general examination that contains a review of these records for that calendar year, whichever is later.

NCGS 58-50-62(e) First-Level Grievance Review. – A covered person or a covered person’s provider acting on the covered person’s behalf may submit a grievance. (1) The insurer does not have to allow a covered person to attend the first-level grievance review. A covered person may submit written material. Except as provided in subdivision (3) of this subsection, within three business days after receiving a grievance, the insurer shall provide the covered person with the name, address, and telephone number of the coordinator and information on how to submit written material. (2) An insurer shall issue a written decision, in clear terms, to the covered person and, if applicable, to the covered person's provider, within 30 days after receiving a grievance. The person or persons reviewing the grievance shall not be the same person or persons who initially handled the matter that is the subject of the grievance and, if the issue is a clinical one, at least one of whom shall be a medical doctor with appropriate expertise to evaluate the matter. Except as provided in subdivision (3) of this subsection, if the decision is not in favor of the covered person, the written decision issued in a first-level grievance review shall contain: a. The professional qualifications and licensure of the person or persons reviewing the grievance. b. A statement of the reviewers' understanding of the grievance. c. The reviewers' decision in clear terms and the contractual basis or medical rationale in sufficient detail for the covered person to respond further to the insurer's position. d. A reference to the evidence or documentation used as the basis for the decision. e. A statement advising the covered person of his or her right to request a second-level grievance review and a description of the procedure for submitting a second-level grievance under this section. f. Notice of the availability of assistance from the Managed Care Patient Assistance Program, including the telephone number and address of the Program. (3) For grievances concerning the quality of care delivered by the covered person’s provider, the insurer shall acknowledge the grievance within 10 business days. The acknowledgement shall advise the covered person that (i) the insurer will refer the grievance to its quality assurance committee for review and consideration or any appropriate action against the provider and (ii) State law does not allow for a second-level grievance review for grievances concerning quality of care.

NCGS 58-50-62(f) Second-Level Grievance Review. – An insurer shall establish a second-level grievance review process for covered persons who are dissatisfied with the first-level grievance review decision or a

NC Dept. of Insurance 22 Market Regulation Division – Domestic Carriers Full Service January 2013 Utilization Review appeal decision. A covered person or the covered person’s provider acting on the covered person’s behalf may submit a second-level grievance. (1) An insurer shall, within 10 business days after receiving a request for a second-level grievance review, make known to the covered person: a. The name, address, and telephone number of a person designated to coordinate the grievance review for the insurer. b. A statement of a covered person's rights, which include the right to request and receive from an insurer all information relevant to the case; attend the second-level grievance review; present his or her case to the review panel; submit supporting materials before and at the review meeting; ask questions of any member of the review panel; and be assisted or represented by a person of his or her choice, which person may be without limitation to: a provider, family member, employer representative, or attorney. If the covered person chooses to be represented by an attorney, the insurer may also be represented by an attorney. c. The availability of assistance from the Managed Care Patient Assistance Program, including the telephone number and address of the Program. (2) An insurer shall convene a second-level grievance review panel for each request. The panel shall comprise persons who were not previously involved in any matter giving rise to the second-level grievance, are not employees of the insurer or URO, and do not have a financial interest in the outcome of the review. A person who was previously involved in the matter may appear before the panel to present information or answer questions. All of the persons reviewing a second-level grievance involving a noncertification or a clinical issue shall be providers who have appropriate expertise, including at least one clinical peer. Provided, however, an insurer that uses a clinical peer on an appeal of a noncertification under G.S. 58-50- 61 or on a first-level grievance review panel under this section may use one of the insurer's employees on the second-level grievance review panel in the same matter if the second-level grievance review panel comprises three or more persons.

NCGS 58-50-62(g) Second-Level Grievance Review Procedures. – An insurer's procedures for conducting a second-level grievance review shall include: (1) The review panel shall schedule and hold a review meeting within 45 days after receiving a request for a second-level review. (2) The covered person shall be notified in writing at least 15 days before the review meeting date. (3) The covered person's right to a full review shall not be conditioned on the covered person's appearance at the review meeting.

NCGS 58-50-62(h) Second-Level Grievance Review Decisions. – An insurer shall issue a written decision to the covered person and, if applicable, to the covered person's provider, within seven business days after completing the review meeting. The decision shall include: (1) The professional qualifications and licensure of the members of the review panel. (2) A statement of the review panel's understanding of the nature of the grievance and all pertinent facts. (3) The review panel's recommendation to the insurer and the rationale behind that recommendation. (4) A description of or reference to the evidence or documentation considered by the review panel in making the recommendation. (5) In the review of a noncertification or other clinical matter, a written statement of the clinical rationale, including the clinical review criteria, that was used by the review panel to make the recommendation. (6) The rationale for the insurer's decision if it differs from the review panel's recommendation. (7) A statement that the decision is the insurer's final determination in the matter. In cases where the review concerned a noncertification and the insurer’s decision on the second-level grievance review NC Dept. of Insurance 23 Market Regulation Division – Domestic Carriers Full Service January 2013 is to uphold its initial noncertification, a statement advising the covered person of his or her right to request an external review and a description of the procedure for submitting a request for external review to the Commissioner of Insurance. (8) Notice of the availability of the Commissioner's office for assistance, including the telephone number and address of the Commissioner's office. (9) Notice of the availability of assistance from the Managed Care Patient Assistance Program, including the telephone number and address of the Program.

NCGS 58-50-62(i) Expedited Second-Level Procedures. – An expedited second-level review shall be made available where medically justified as provided in G.S. 58-50-61(l), whether or not the initial review was expedited. The provisions of subsections (f), (g), and (h) of this section apply to this subsection except for the following timetable: When a covered person is eligible for an expedited second-level review, the insurer shall conduct the review proceeding and communicate its decision within four days after receiving all necessary information. The review meeting may take place by way of a telephone conference call or through the exchange of written information.

NCGS 58-50-62(j) – No insurer shall discriminate against any provider based on any action taken by the provider under this section or G.S. 58-50-61 on behalf of a covered person.

NCGS 58-50-62(k) Violation. – A violation of this section subjects an insurer to G.S. 58-2-70. (1997-519, s. 4.2.)

NC Dept. of Insurance 24 Market Regulation Division – Domestic Carriers Full Service January 2013 MARKET REGULATION DIVISION C4b. Compliance Certification: Delegated External Review related to Grievances

Pursuant to NCGS 58-3-191 (“Managed Care Reporting and Disclosure Requirements”) and NCGS 58-50-77, 58-50-79, 58-50-80 and 58-50-82 (“External Review”), (“Insurer”), duly licensed and authorized to do business in the State of North Carolina, hereby provides notification that it has delegated External Review responsibilities to (“Delegated Entity”). Insurer certifies to the Commissioner of the North Carolina Department of Insurance that the Delegated Entity’s External Review program, and the Insurer’s oversight/monitoring of that program, is compliant with the Statutes listed and referenced below. Note: The actual documentation will be required at the Market Regulation Division’s next scheduled Market Conduct Examination of the Insurer or at the discretion of the Department.

III. Applicable Statutes

NCGS 58 - 50 - 77 Notice of right to external review. (a) An insurer shall notify the covered person in writing of the covered person's right to request an external review and include the appropriate statements and information set forth in this section at the time the insurer sends written notice of: (1) A noncertification decision under G.S. 58-50-61; (2) An appeal decision under G.S. 58-50-61 upholding a noncertification; and (3) A second-level grievance review decision under G.S. 58-50-62 upholding the original noncertification. (b) The insurer shall include in the notice required under subsection (a) of this section for a notice related to a noncertification decision under G.S. 58-50-61, a statement informing the covered person that if the covered person has a medical condition where the time frame for completion of an expedited review of an appeal decision involving a noncertification decision under G.S. 58-50-61 would reasonably be expected to seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, then the covered person may file a request for an expedited external review under G.S. 58-50-82 at the same time the covered person files a request for an expedited review of an appeal involving a noncertification decision under G.S. 58-50-61, but that the Commissioner will determine whether the covered person shall be required to complete the expedited review of the grievance before conducting the expedited external review. (c) The insurer shall include in the notice required under subsection (a) of this section for a notice related to an appeal decision under G.S. 58-50-61, a statement informing the covered person that: (1) If the covered person has a medical condition where the time frame for completion of an expedited review of a grievance involving an appeal decision under G.S. 58-50-61 would reasonably be expected to seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, the covered person may file a request for an expedited external review under G.S. 58-50-82 at the same time the covered person files a request for an expedited review of a grievance involving an appeal decision under G.S. 58-50-62, but that the Commissioner will determine whether the covered person shall be required to complete the expedited review of the grievance before conducting the expedited external review. (2) If the covered person has not received a written decision from the insurer within 60 days after the date the covered person files the second- level grievance with the insurer pursuant to G.S. 58-50-62 and the covered person has not requested or agreed to a delay, the covered

NC Dept. of Insurance 25 Market Regulation Division – Domestic Carriers Full Service January 2013 person may file a request for external review under G.S. 58-50-80 and shall be considered to have exhausted the insurer's internal grievance process for purposes of G.S. 58-50-79. (d) The insurer shall include in the notice required under subsection (a) of this section for a notice related to a final second-level grievance review decision under G.S. 58-50-62, a statement informing the covered person that: (1) If the covered person has a medical condition where the time frame for completion of a standard external review under G.S. 58-50-80 would reasonably be expected to seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, the covered person may file a request for an expedited external review under G.S. 58-50-82; or (2) If the second-level grievance review decision concerns an admission, availability of care, continued stay, or health care service for which the covered person received emergency services but has not been discharged from a facility, the covered person may request an expedited external review under G.S. 58-50-82. (e) In addition to the information to be provided under this section, the insurer shall include a copy of the description of both the standard and expedited external review procedures the insurer is required to provide under G.S. 58-50-93, including the provisions in the external review procedures that give the covered person the opportunity to submit additional information. (2001-446, s. 4.5.)

NCGS 58 - 50 - 80 Standard external review. (e) Failure by the insurer or its designee utilization review organization to provide the documents and information within the time specified in this subsection shall not delay the conduct of the external review.

NC Dept. of Insurance 26 Market Regulation Division – Domestic Carriers Full Service January 2013 However, if the insurer or its utilization review organization fails to provide the documents and information within the time specified in subdivision (b)(4) of this section, the assigned organization may terminate the external review and make a decision to reverse the noncertification appeal decision or the second-level grievance review decision. Within one business day of making the decision under this subsection, the organization shall notify the covered person, the insurer, and the Commissioner. (g) Upon receipt of the information required to be forwarded under subsection (f) of this section, the insurer may reconsider its noncertification appeal decision or second-level grievance review decision that is the subject of the external review. Reconsideration by the insurer of its noncertification appeal decision or second-level grievance review decision under this subsection shall not delay or terminate the external review. The external review shall be terminated if the insurer decides, upon completion of its reconsideration, to reverse its noncertification appeal decision or second-level grievance review decision and provide coverage or payment for the requested health care service that is the subject of the noncertification appeal decision or second-level grievance review decision. (h) Upon making the decision to reverse its noncertification appeal decision or second-level grievance review decision under subsection (g) of this section, the insurer shall notify the covered person, the organization, and the Commissioner in writing of its decision. The organization shall terminate the external review upon receipt of the notice from the insurer sent under this subsection. (l) Upon receipt of a notice of a decision under subsection (k) of this section reversing the noncertification appeal decision or second-level grievance review decision, the insurer shall within three business days reverse the noncertification appeal decision or second-level grievance review decision that was the subject of the review and shall provide coverage or payment for the requested health care service or supply that was the subject of the noncertification appeal decision or second-level grievance review decision. In the event the covered person is no longer enrolled in the health benefit plan when the insurer receives notice of a decision under subsection (k) of this section reversing the noncertification appeal decision or second-level grievance review decision, the insurer that made the noncertification appeal decision or second-level grievance review decision shall be responsible under this section only for the costs of those services or supplies the covered person received or would have received prior to disenrollment if the service had not been denied when first requested.

NCGS 58 - 50 - 82 Expedited external review. (c) As soon as possible, but within the same business day of receiving notice under subdivision (b)(2) of this section that the request has been assigned to a review organization, the insurer or its designee utilization review organization shall provide or transmit all documents and information considered in making the noncertification appeal decision or the second-level grievance review decision to the assigned review organization electronically or by telephone or facsimile or any other available expeditious method. A copy of the same information shall be sent by the same means or other expeditious means to the covered person or the covered person's representative who made the request for expedited external review. (f) If the notice provided under subsection (e) of this section was not in writing, within two days after the date of providing that notice, the assigned organization shall provide written confirmation of the decision to the covered person, the covered person's provider who performed or requested the service, the insurer, and the Commissioner and include the information set forth in G.S. 58-50-80(m).

Upon receipt of the notice of a decision under subsection (e) of this section that reverses the noncertification, noncertification appeal decision, or second-level grievance review decision, the insurer shall within one day reverse the noncertification, noncertification appeal decision, or NC Dept. of Insurance 27 Market Regulation Division – Domestic Carriers Full Service January 2013 second-level grievance review decision that was the subject of the review and shall provide coverage or payment for the requested health care service or supply that was the subject of the noncertification, noncertification appeal decision, or second-level grievance review decision.

NC Dept. of Insurance 28 Market Regulation Division – Domestic Carriers Full Service January 2013 II. Monitoring Activities IMPORTANT NOTE: Answer the following questions applicable to Data Year 2012.

To demonstrate compliance with NCGS 58-3-191 and NCGS 58-50-62, Insurers who delegate Grievance responsibilities to a Delegated Entity must complete this document using the text boxes provided. Do not attach any additional documentation.

To demonstrate compliance with NCGS 58-3-191 and NCGS 58-50-77, NCGS 58-50-79, NCGS 58-50-80 and NCGS 58-50-82, Insurers who delegate External Review programs must provide requested information within the text boxes below. Do not attach any additional documentation.

Delegated Entity Handling Grievances:

Check all type(s) of Grievances the Delegated Entity conducts on services provided to NC insureds: Informal Consideration 1st Level 2nd Level External Review

Check all type(s) of Grievances notifications developed and mailed by the Delegated Entity to NC insureds: Informal Consideration 1st Level 2nd Level External Review

Question 1: Identify each version of the Delegated Entity’s Grievance Program - Policies & Procedures (P&Ps) including related form/template letters effective during the specified data year.

Answer 1:

Name of the Delegated Entity’s P&Ps, including any identification number/revision date: Date P&Ps approved internally by the Delegated Entity: Who from the Delegated Entity approved the P&Ps (i.e. Board of Directors, Committee or Officer)? (Must provide names and titles): Effective Date of the Delegated Entity’s P&Ps:

Who from the Insurer (i.e. Board of Directors, Committee or Officer) approved the Delegated Entity’s P&Ps? (Must provide names and titles): Date Insurer approved the Delegated Entity’s P&Ps:

Question 2: Does the delegated Grievance Program – Policies & Procedures (P&Ps) include mental health/chemical dependency and/or pharmacy benefit programs? If not, be sure to separately identify each of these policies.

Answer 2:

Question 3: Identify version of the Insurer’s internal Policies & Procedures (P&Ps) for oversight of the Delegated Entity’s Grievance program effective during the specified data year.

NC Dept. of Insurance 29 Market Regulation Division – Domestic Carriers Full Service January 2013 Answer 3:

Name of the Insurer’s Oversight P&Ps, including any identification number/revision date: Who from the Insurer approved the Oversight P&Ps (i.e. Board of Directors, Committee or Officer)? (Must provide names and titles): Date Insurer approved the P&Ps: Effective Date of P&Ps:

Question 4: Does the Insurer’s oversight Policies & Procedures (P&Ps) of the Delegated Entity’s Grievance Program include mental health/chemical dependency and/or pharmacy benefit programs? If not, be sure to separately identify each of these policies.

Answer 4:

Question 5: When did the Insurer complete its most recent review of the Delegated Entity’s Grievance program – Policies & Procedures (P&Ps)? (Must specify month/year)

Answer 5:

Question 6: When does the Insurer anticipate conducting its next review of the Delegated Entity’s Grievance program - Policies & Procedures (P&Ps)? (Must specify month/year)

Answer 6:

Question 7: When did the Insurer complete its most recent review of the Delegated Entity’s Grievance related form/template letters as referenced in NCGS 58-50-62, NCGS 58-50-77, 58-50- 79, 58-50-80 and 58-50-82? (Must specify month/year)

Answer 7:

Question 8: When did the Insurer complete its most recent audit sampling of the Delegated Entity’s actual correspondence as referenced in NCGS 58-50-62, NCGS 58-50-77, 58-50-79, 58-50-80 and 58-50-82? (Must specify month/year)

Answer 8:

Question 9: Specify the number of actual cases reviewed. (Applicable to Question/Answer #8)

Answer 9:

NC Dept. of Insurance 30 Market Regulation Division – Domestic Carriers Full Service January 2013 Question 10: What was the Company’s rationale in determining the number of cases reviewed? (Applicable to Question/Answer #9)

Answer 10:

Question 11: Were all of the Delegated Entity’s case correspondence compliant (language and time requirements) with State law and did they include External Review Rights when required? If not explain any deficiencies found, along with corrective actions taken and/or planned.

Answer 11:

Question 12: Identify areas of non-compliance with the Delegated Entity’s Grievance Program – Policies & Procedures (P&Ps) including the related form/template letters, along with corrective actions taken and/or planned.

Answer 12:

NC Dept. of Insurance 31 Market Regulation Division – Domestic Carriers Full Service January 2013 MARKET REGULATION DIVISION C5a. Compliance Certification: Utilization Review

Pursuant to NCGS 58-3-191 (“Managed Care Reporting and Disclosure Requirements”) and NCGS 58-50-61 (“Utilization Review”), (“Insurer”), duly licensed and authorized to do business in the State of North Carolina, certifies to the Commissioner of the North Carolina Department of Insurance that its Utilization Review program is compliant with the Statutes listed and referenced below (except to the extent of exceptions noted in Section II of this certification). Note: The actual documentation will be required at the Market Regulation Division’s next scheduled Market Conduct Examination of the Insurer or at the discretion of the Department.

NCGS 58-50-61(a) Definitions. (See actual statute)

NCGS 58-50-61(b) Insurer Oversight. – Every insurer shall monitor all Utilization Review carried out by or on behalf of the insurer and ensure compliance with this section. An insurer shall ensure that appropriate personnel have operational responsibility for the conduct of the insurer’s Utilization Review program. If an insurer contracts to have a URO perform its Utilization Review, the insurer shall monitor the URO to ensure compliance with this section, which shall include: (1) A written description of the URO’s activities and responsibilities, including reporting requirements. (2) Evidence of formal approval of the Utilization Review organization program by the insurer. (3) A process by which the insurer evaluates the performance of the URO. Prior to contracting with the Delegated Entity, the Insurer reviewed and approved the Delegated Entity’s credential verification program.

NCGS 58-50-61(c) Scope and Content of Program. – Every insurer shall prepare and maintain a Utilization Review program document that describes all delegated and nondelegated review functions for covered services including: (1) Procedures to evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health services. (2) Data sources and clinical review criteria used in decision making. (3) The process for conducting appeals of noncertifications. (4) Mechanisms to ensure consistent application of review criteria and compatible decisions. (5) Data collection processes and analytical methods used in assessing utilization of health care services. (6) Provisions for assuring confidentiality of clinical and patient information in accordance with State and federal law. (7) The organizational structure (e.g., Utilization Review committee, quality assurance, or other committee) that periodically assesses Utilization Review activities and reports to the insurer’s governing body. (8) The staff position functionally responsible for day-to-day program management. (9) The methods of collection and assessment of data about underutilization and overutilization of health care services and how the assessment is used to evaluate and improve procedures and criteria for Utilization Review.

NCGS 58-50-61(d) Program Operations. – In every Utilization Review program, an insurer or URO shall use documented clinical review criteria that are based on sound clinical evidence and that are periodically evaluated to assure ongoing efficacy. An insurer may develop its own clinical review criteria or purchase or NC Dept. of Insurance 32 Market Regulation Division – Domestic Carriers Full Service January 2013 license clinical review criteria. Criteria for determining when a patient needs to be placed in a substance abuse treatment program shall be either (i) the diagnostic criteria contained in the most recent revision of the American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Substance- Related Disorders or (ii) criteria adopted by the insurer or it’s URO. The Department, in consultation with the Department of Health and Human Services, may require proof of compliance with this subsection by a plan or URO.

Qualified health care professionals shall administer the Utilization Review program and oversee review decisions under the direction of a medical doctor. A medical doctor licensed to practice medicine in this State shall evaluate the clinical appropriateness of noncertifications. Compensation to persons involved in Utilization Review shall not contain any direct or indirect incentives for them to make any particular review decisions. Compensation to Utilization Reviewers shall not be directly or indirectly based on the number or type of noncertifications they render. In issuing a Utilization Review decision, an insurer shall: obtain all information required to make the decision, including pertinent clinical information; employ a process to ensure that Utilization Reviewers apply clinical review criteria consistently; and issue the decision in a timely manner pursuant to this section.

NCGS 58-50-61(e) Insurer Responsibilities. – Every insurer shall: (1) Routinely assess the effectiveness and efficiency of its Utilization Review program. (2) Coordinate the Utilization Review program with its other medical management activity, including quality assurance, credentialing, provider contracting, data reporting, grievance procedures, processes for assessing satisfaction of covered persons, and risk management. (3) Provide covered persons and their providers with access to its review staff by a toll-free or collect call telephone number whenever any provider is required to be available to provide services which may require prior certification to any plan enrollee. Every insurer shall establish standards for telephone accessibility and monitor telephone service as indicated by average speed of answer and call abandonment rate, on at least a month-by-month basis, to ensure that telephone service is adequate, and take corrective action when necessary. (4) Limit its requests for information to only that information that is necessary to certify the admission, procedure or treatment, length of stay, and frequency and duration of health care services. (5) Have written procedures for making Utilization Review decisions and for notifying covered persons of those decisions. (6) Have written procedures to address the failure or inability of a provider or covered person to provide all necessary information for review. If a provider or covered person fails to release necessary information in a timely manner, the insurer may deny certification.

NCGS 58-50-61(f) Prospective and Concurrent Reviews. – As used in this subsection, “necessary information” includes the results of any patient examination, clinical evaluation, or second opinion that may be required. Prospective and concurrent determinations shall be communicated to the covered person’s provider within three business days after the insurer obtains all necessary information about the admission, procedure, or health care service. If an insurer certifies a health care service, the insurer shall notify the covered person’s provider. For a noncertification, the insurer shall notify the covered person’s provider and send written or electronic confirmation of the noncertification to the covered person. In concurrent reviews, the insurer shall remain liable for health care services until the covered person has been notified of the noncertification.

NCGS 58-50-61(g) Retrospective Reviews. – As used in this subsection, “necessary information” includes the results of any patient examination, clinical evaluation, or second opinion that may be required. For retrospective review determinations, an insurer shall make the determination within 30 days after receiving all necessary information. For a certification, the insurer may give written notification to the covered NC Dept. of Insurance 33 Market Regulation Division – Domestic Carriers Full Service January 2013 person’s provider. For a noncertification, the insurer shall give written notification to the covered person and the covered person’s provider within five business days after making the noncertification.

NCGS 58-50-61(h) Notice of Noncertification. – A written notification of a noncertification shall include all reasons for the noncertification, including the clinical rationale, the instructions for initiating a voluntary appeal or reconsideration of the noncertification, and the instructions for requesting a written statement of the clinical review criteria used to make the noncertification. An insurer shall provide the clinical review criteria used to make the noncertification to any person who received the notification of the noncertification and who follows the procedures for a request. An insurer shall also inform the covered person in writing about the availability of assistance from the Managed Care Patient Assistance Program, including the telephone number and address of the Program.

NCGS 58-50-61(i) Requests for Informal Reconsideration. – An insurer may establish procedures for informal reconsideration of noncertifications and, if established, the procedures shall be in writing. After a written notice of noncertification has been issued in accordance with subsection (h) of this section, the reconsideration shall be conducted between the covered person’s provider and a medical doctor licensed to practice medicine in this State designated by the insurer. An insurer shall not require a covered person to participate in an informal reconsideration before the covered person may appeal a noncertification under subsection (j) of this section. If, after informal reconsideration, the insurer upholds the noncertification decision, the insurer shall issue a new notice in accordance with subsection (h) of this section. If the insurer is unable to render an informal reconsideration decision within 10 business days after the date of receipt of the request for an informal reconsideration, it shall treat the request for informal reconsideration as a request for an appeal; provided that the requirements of subsection (k) of this section for acknowledging the request shall apply beginning on the day the insurer determines an informal reconsideration decision cannot be made before the tenth business day after receipt of the request for an informal reconsideration.

NCGS 58-50-61(j) Appeals of Noncertifications. – Every insurer shall have written procedures for appeals of noncertifications by covered persons or their providers acting on their behalves, including expedited review to address a situation where the time frames for the standard review procedures set forth in this section would reasonably appear to seriously jeopardize the life or health of a covered person or jeopardize the covered person’s ability to regain maximum function. Each appeal shall be evaluated by a medical doctor licensed to practice medicine in this State who was not involved in the noncertification.

NCGS 58-50-61(k) Nonexpedited Appeals. – Within three business days after receiving a request for a standard, nonexpedited appeal, the insurer shall provide the covered person with the name, address, and telephone number of the coordinator and information on how to submit written material. For standard, nonexpedited appeals, the insurer shall give written notification of the decision, in clear terms, to the covered person and the covered person’s provider within 30 days after the insurer receives the request for an appeal. If the decision is not in favor of the covered person, the written decision shall contain: (1) The professional qualifications and licensure of the person or persons reviewing the appeal. (2) A statement of the reviewers’ understanding of the reason for the covered person’s appeal. (3) The reviewers’ decision in clear terms and the medical rationale in sufficient detail for the covered person to respond further to the insurer’s position. (4) A reference to the evidence or documentation that is the basis for the decision, including the clinical review criteria used to make the determination, and instructions for requesting the clinical review criteria. (5) A statement advising the covered person of the covered person’s right to request a second-level grievance review and a description of the procedure for submitting a second-level grievance under G.S. 58-50-62. NC Dept. of Insurance 34 Market Regulation Division – Domestic Carriers Full Service January 2013 Note: the second-level process is addressed by NCGS 58-50-62, “Insurer Grievance Procedures” (6) Notice of the availability of assistance from the Managed Care Patient Assistance Program including the telephone number and address of the Program.

NCGS 58-50-61(l) Expedited Appeals. – An expedited appeal of a noncertification may be requested by a covered person or his or her provider acting on the covered person's behalf only when a nonexpedited appeal would reasonably appear to seriously jeopardize the life or health of a covered person or jeopardize the covered person's ability to regain maximum function. The insurer may require documentation of the medical justification for the expedited appeal. The insurer shall, in consultation with a medical doctor licensed to practice medicine in this State, provide expedited review, and the insurer shall communicate its decision in writing to the covered person and his or her provider as soon as possible, but not later than four days after receiving the information justifying expedited review. The written decision shall contain the provisions specified in subsection (k) of this section. If the expedited review is a concurrent review determination, the insurer shall remain liable for the coverage of health care services until the covered person has been notified of the determination. An insurer is not required to provide an expedited review for retrospective noncertifications.

NCGS 58-50-61(m) Disclosure Requirements. – In the certificate of coverage and member handbook provided to covered persons, an insurer shall include a clear and comprehensive description of its Utilization Review procedures, including the procedures for appealing noncertifications and a statement of the rights and responsibilities of covered persons, including the voluntary nature of the appeal process, with respect to those procedures. An insurer shall also include in the certificate of coverage and the member handbook information about the availability of assistance from the Managed Care Patient Assistance Program, including the telephone number and address of the Program. An insurer shall include a summary of its Utilization Review procedures in materials intended for prospective covered persons. An insurer shall print on its membership cards a toll-free telephone number to call for Utilization Review purposes.

NCGS 58-50-61(n) Maintenance of Records. – Every insurer and URO shall maintain records of each review performed and each appeal received or reviewed, as well as documentation sufficient to demonstrate compliance with this section. The maintenance of these records, including electronic reproduction and storage, shall be governed by rules adopted by the Commissioner that apply to insurers. These records shall be retained by the insurer and URO for a period of five years or until the Commissioner has adopted a final report of a general examination that contains a review of these records for that calendar year, whichever is later.

NCGS 58-50-61(o) Violation. – A violation of this section subjects an insurer to G.S. 58-2-70. (1997-443, s. 11A.122; 1997-519, s. 4.1; 1999-116, s. 1; 1999-391, ss. 1-4.)

NC Dept. of Insurance 35 Market Regulation Division – Domestic Carriers Full Service January 2013 MARKET REGULATION DIVISION C5b. Compliance Certification: External Review

Pursuant to NCGS 58-3-191 (“Managed Care Reporting and Disclosure Requirements”) and NCGS 58-50-77, 58-50-79, 58-50-80 and 58-50-82 (“External Review”), (“Insurer”), duly licensed and authorized to do business in the State of North Carolina, certifies to the Commissioner of the North Carolina Department of Insurance that its External Review program is compliant with the Statutes listed and referenced below. Note: The actual documentation will be required at the Market Regulation Division’s next scheduled Market Conduct Examination of the Insurer or at the discretion of the Department.

IV. Applicable Statutes

NCGS 58 - 50 - 77 Notice of right to external review. (a) An insurer shall notify the covered person in writing of the covered person's right to request an external review and include the appropriate statements and information set forth in this section at the time the insurer sends written notice of: (1) A noncertification decision under G.S. 58-50-61; (2) An appeal decision under G.S. 58-50-61 upholding a noncertification; and (3) A second-level grievance review decision under G.S. 58-50-62 upholding the original noncertification. (b) The insurer shall include in the notice required under subsection (a) of this section for a notice related to a noncertification decision under G.S. 58-50-61, a statement informing the covered person that if the covered person has a medical condition where the time frame for completion of an expedited review of an appeal decision involving a noncertification decision under G.S. 58-50-61 would reasonably be expected to seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, then the covered person may file a request for an expedited external review under G.S. 58-50-82 at the same time the covered person files a request for an expedited review of an appeal involving a noncertification decision under G.S. 58-50-61, but that the Commissioner will determine whether the covered person shall be required to complete the expedited review of the grievance before conducting the expedited external review. (c) The insurer shall include in the notice required under subsection (a) of this section for a notice related to an appeal decision under G.S. 58-50-61, a statement informing the covered person that: (1) If the covered person has a medical condition where the time frame for completion of an expedited review of a grievance involving an appeal decision under G.S. 58-50-61 would reasonably be expected to seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, the covered person may file a request for an expedited external review under G.S. 58-50-82 at the same time the covered person files a request for an expedited review of a grievance involving an appeal decision under G.S. 58-50-62, but that the Commissioner will determine whether the covered person shall be required to complete the expedited review of the grievance before conducting the expedited external review. (2) If the covered person has not received a written decision from the insurer within 60 days after the date the covered person files the second- level grievance with the insurer pursuant to G.S. 58-50-62 and the covered person has not requested or agreed to a delay, the covered person may file a request for external review under G.S. 58-50-80 and shall be considered to have exhausted the insurer's internal grievance process for purposes of G.S. 58-50-79.

NC Dept. of Insurance 36 Market Regulation Division – Domestic Carriers Full Service January 2013 (d) The insurer shall include in the notice required under subsection (a) of this section for a notice related to a final second-level grievance review decision under G.S. 58-50-62, a statement informing the covered person that: (1) If the covered person has a medical condition where the time frame for completion of a standard external review under G.S. 58-50-80 would reasonably be expected to seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, the covered person may file a request for an expedited external review under G.S. 58-50-82; or (2) If the second-level grievance review decision concerns an admission, availability of care, continued stay, or health care service for which the covered person received emergency services but has not been discharged from a facility, the covered person may request an expedited external review under G.S. 58-50-82. (e) In addition to the information to be provided under this section, the insurer shall include a copy of the description of both the standard and expedited external review procedures the insurer is required to provide under G.S. 58-50-93, including the provisions in the external review procedures that give the covered person the opportunity to submit additional information. (2001-446, s. 4.5.)

NCGS 58 - 50 - 80 Standard external review. (e) Failure by the insurer or its designee utilization review organization to provide the documents and information within the time specified in this subsection shall not delay the conduct of the external review. However, if the insurer or its utilization review organization fails to provide the documents and information within the time specified in subdivision (b)(4) of this section, the assigned organization may terminate the external review and make a decision to reverse the noncertification appeal decision or the second-level grievance review decision. Within one business day of making

NC Dept. of Insurance 37 Market Regulation Division – Domestic Carriers Full Service January 2013 the decision under this subsection, the organization shall notify the covered person, the insurer, and the Commissioner. (g) Upon receipt of the information required to be forwarded under subsection (f) of this section, the insurer may reconsider its noncertification appeal decision or second-level grievance review decision that is the subject of the external review. Reconsideration by the insurer of its noncertification appeal decision or second-level grievance review decision under this subsection shall not delay or terminate the external review. The external review shall be terminated if the insurer decides, upon completion of its reconsideration, to reverse its noncertification appeal decision or second-level grievance review decision and provide coverage or payment for the requested health care service that is the subject of the noncertification appeal decision or second-level grievance review decision. (h) Upon making the decision to reverse its noncertification appeal decision or second-level grievance review decision under subsection (g) of this section, the insurer shall notify the covered person, the organization, and the Commissioner in writing of its decision. The organization shall terminate the external review upon receipt of the notice from the insurer sent under this subsection. (l) Upon receipt of a notice of a decision under subsection (k) of this section reversing the noncertification appeal decision or second-level grievance review decision, the insurer shall within three business days reverse the noncertification appeal decision or second-level grievance review decision that was the subject of the review and shall provide coverage or payment for the requested health care service or supply that was the subject of the noncertification appeal decision or second-level grievance review decision. In the event the covered person is no longer enrolled in the health benefit plan when the insurer receives notice of a decision under subsection (k) of this section reversing the noncertification appeal decision or second-level grievance review decision, the insurer that made the noncertification appeal decision or second-level grievance review decision shall be responsible under this section only for the costs of those services or supplies the covered person received or would have received prior to disenrollment if the service had not been denied when first requested.

NCGS 58 - 50 - 82 Expedited external review. (c) As soon as possible, but within the same business day of receiving notice under subdivision (b)(2) of this section that the request has been assigned to a review organization, the insurer or its designee utilization review organization shall provide or transmit all documents and information considered in making the noncertification appeal decision or the second-level grievance review decision to the assigned review organization electronically or by telephone or facsimile or any other available expeditious method. A copy of the same information shall be sent by the same means or other expeditious means to the covered person or the covered person's representative who made the request for expedited external review. (f) If the notice provided under subsection (e) of this section was not in writing, within two days after the date of providing that notice, the assigned organization shall provide written confirmation of the decision to the covered person, the covered person's provider who performed or requested the service, the insurer, and the Commissioner and include the information set forth in G.S. 58-50-80(m). Upon receipt of the notice of a decision under subsection (e) of this section that reverses the noncertification, noncertification appeal decision, or second-level grievance review decision, the insurer shall within one day reverse the noncertification, noncertification appeal decision, or second-level grievance review decision that was the subject of the review and shall provide coverage or payment for the requested health care service or supply that was the subject of the noncertification, noncertification appeal decision, or second-level grievance review decision.

NC Dept. of Insurance 38 Market Regulation Division – Domestic Carriers Full Service January 2013 II. Monitoring Activities IMPORTANT NOTE: Answer the following questions applicable to Data Year 2012

To demonstrate compliance with NCGS 58-3-191 and NCGS 58-50-61, Insurers with their own Utilization Review programs must provide requested information within the text boxes below. Do not attach any additional documentation. To demonstrate compliance with NCGS 58-3-191 and NCGS 58-50-77, NCGS 58-50-79, NCGS 58-50-80 and NCGS 58-50-82, Insurers with their own External Review programs must provide requested information within the text boxes below. Do not attach any additional documentation.

Check all type(s) of Reviews the Plan conducts on services provided to NC insureds: Utilization Review: Prospective Concurrent Retrospective Informal Reconsideration Noncert Appeals – 1st Level Noncert Appeals – 2nd Level External Review

Check all type(s) of notification letters developed and mailed by the Plan to NC insureds: Utilization Review: Prospective Concurrent Retrospective Informal Reconsideration Noncert Appeals – 1st Level Noncert Appeals – 2nd Level External Review

Question 1: Identify each version of the Insurer’s Utilization Review Program - Policies & Procedures (P&Ps) including related form/template letters effective during the specified data year.

Answer 1:

Question 2: Does the Utilization Review Program – Policies & Procedures (P&Ps) include mental health/chemical dependency and/or pharmacy benefit programs? If not, be sure to separately identify each of these policies.

Answer 2:

Question 3: When did the Insurer complete its most recent review of its own Utilization Review program – Policies & Procedures (P&Ps)? (Must specify month/year)

Answer 3:

NC Dept. of Insurance 39 Market Regulation Division – Domestic Carriers Full Service January 2013 Question 4: When does the Insurer anticipate conducting its next review of its own Utilization Review program – Policies & Procedures (P&Ps)? (Must specify month/year)

Answer 4:

Question 5: When did the Insurer complete its most recent review of its UR related form/template letters as referenced in NCGS 58-50-61, NCGS 58-50-77, 58-50-79, 58-50-80 and 58-50-82? (Must specify month/year)

Answer 5:

Question 6: When did the Insurer complete its most recent audit sampling of actual case correspondence as referenced in NCGS 58-50-61, NCGS 58-50-77, 58-50-79, 58-50-80 and 58-50- 82? (Must specify month/year)

Answer 6:

Question 7: Specify the number of actual cases reviewed. (Applicable to Question/Answer #6)

Answer 7:

Answer 8:

Question 9: Were all the case correspondence compliant (language and time requirements) with State law and did they include External Review Rights when required? If not explain any deficiencies found, along with corrective actions taken and/or planned.

Answer 9:

Question 10: Identify areas of non-compliance with Utilization Review Policies & Procedures (P&Ps) including the related form/template letters, along with corrective actions taken and/or planned.

Answer 10:

NC Dept. of Insurance 40 Market Regulation Division – Domestic Carriers Full Service January 2013 Question 11: What is/are the position title(s) and clinical degree(s) of staff member(s) who have ultimate oversight responsibility for the Insurer’s Utilization Review program (If more than one person, clarify the duties for each)?

Answer 11:

Question 12: What is/are the position title(s) and clinical degree(s) of staff members who have ultimate operational responsibility for the Insurer’s Utilization Review program (If more than one person, clarify the duties for each)?

Answer 12:

Question 13: Provide the following information regarding the individual(s) making noncertification decisions: (Insert additional lines as necessary)

*Note if the Insurer uses an outside organization properly identify the organization and list those individual(s) within the organization making noncertification decisions. If additional space is needed, an attachment may be used.

Answer 13:

Name: Clinical Degree: State(s) where clinical degree/license is active and in good standing:

NC Dept. of Insurance 41 Market Regulation Division – Domestic Carriers Full Service January 2013 MARKET REGULATION DIVISION C6a. Compliance Certification: Delegated Utilization Review

Pursuant to NCGS 58-3-191 (“Managed Care Reporting and Disclosure Requirements”) and NCGS 58-50-61 (“Utilization Review”), (“Insurer”), duly licensed and authorized to do business in the State of North Carolina, hereby provides notification that it has delegated Utilization Review responsibilities to (“Delegated Entity”). Insurer certifies to the Commissioner of the North Carolina Department of Insurance that the Delegated Entity’s Utilization Review program, and the Insurer’s oversight/monitoring of that program, is compliant with the Statutes listed and referenced below (except to the extent of exceptions noted in Section II of this certification). Note: The actual documentation will be required at the Market Regulation Division’s next scheduled Market Conduct Examination of the Insurer or at the discretion of the Department.

NCGS 58-50-61(b) Insurer Oversight. – Every insurer shall monitor all Utilization Review carried out by or on behalf of the insurer and ensure compliance with this section. An insurer shall ensure that appropriate personnel have operational responsibility for the conduct of the insurer’s Utilization Review program. If an insurer contracts to have a URO perform its Utilization Review, the insurer shall monitor the URO to ensure compliance with this section, which shall include: (1) A written description of the URO’s activities and responsibilities, including reporting requirements. (2) Evidence of formal approval of the Utilization Review organization program by the insurer. (3) A process by which the insurer evaluates the performance of the URO. Prior to contracting with the Delegated Entity, the Insurer reviewed and approved the Delegated Entity’s credential verification program.

NCGS 58-50-61(c) Scope and Content of Program. – Every insurer shall prepare and maintain a Utilization Review program document that describes all delegated and nondelegated review functions for covered services including: (1) Procedures to evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health services. (2) Data sources and clinical review criteria used in decision making. (3) The process for conducting appeals of noncertifications. (4) Mechanisms to ensure consistent application of review criteria and compatible decisions. (5) Data collection processes and analytical methods used in assessing utilization of health care services. (6) Provisions for assuring confidentiality of clinical and patient information in accordance with State and federal law. (7) The organizational structure (e.g., Utilization Review committee, quality assurance, or other committee) that periodically assesses Utilization Review activities and reports to the insurer’s governing body. (8) The staff position functionally responsible for day-to-day program management. (9) The methods of collection and assessment of data about underutilization and overutilization of health care services and how the assessment is used to evaluate and improve procedures and criteria for Utilization Review.

NCGS 58-50-61(d) Program Operations. – In every Utilization Review program, an insurer or URO shall use documented clinical review criteria that are based on sound clinical evidence and that are periodically NC Dept. of Insurance 42 Market Regulation Division – Domestic Carriers Full Service January 2013 evaluated to assure ongoing efficacy. An insurer may develop its own clinical review criteria or purchase or license clinical review criteria. Criteria for determining when a patient needs to be placed in a substance abuse treatment program shall be either (i) the diagnostic criteria contained in the most recent revision of the American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Substance- Related Disorders or (ii) criteria adopted by the insurer or it’s URO. The Department, in consultation with the Department of Health and Human Services, may require proof of compliance with this subsection by a plan or URO.

Qualified health care professionals shall administer the Utilization Review program and oversee review decisions under the direction of a medical doctor. A medical doctor licensed to practice medicine in this State shall evaluate the clinical appropriateness of noncertifications. Compensation to persons involved in Utilization Review shall not contain any direct or indirect incentives for them to make any particular review decisions. Compensation to Utilization Reviewers shall not be directly or indirectly based on the number or type of noncertifications they render. In issuing a Utilization Review decision, an insurer shall: obtain all information required to make the decision, including pertinent clinical information; employ a process to ensure that Utilization Reviewers apply clinical review criteria consistently; and issue the decision in a timely manner pursuant to this section.

NCGS 58-50-61(e) Insurer Responsibilities. – Every insurer shall: (1) Routinely assess the effectiveness and efficiency of its Utilization Review program. (2) Coordinate the Utilization Review program with its other medical management activity, including quality assurance, credentialing, provider contracting, data reporting, grievance procedures, processes for assessing satisfaction of covered persons, and risk management. (3) Provide covered persons and their providers with access to its review staff by a toll-free or collect call telephone number whenever any provider is required to be available to provide services which may require prior certification to any plan enrollee. Every insurer shall establish standards for telephone accessibility and monitor telephone service as indicated by average speed of answer and call abandonment rate, on at least a month-by-month basis, to ensure that telephone service is adequate, and take corrective action when necessary. (4) Limit its requests for information to only that information that is necessary to certify the admission, procedure or treatment, length of stay, and frequency and duration of health care services. (5) Have written procedures for making Utilization Review decisions and for notifying covered persons of those decisions. (6) Have written procedures to address the failure or inability of a provider or covered person to provide all necessary information for review. If a provider or covered person fails to release necessary information in a timely manner, the insurer may deny certification.

NCGS 58-50-61(f) Prospective and Concurrent Reviews. – As used in this subsection, "necessary information" includes the results of any patient examination, clinical evaluation, or second opinion that may be required. Prospective and concurrent determinations shall be communicated to the covered person's provider within three business days after the insurer obtains all necessary information about the admission, procedure, or health care service. If an insurer certifies a health care service, the insurer shall notify the covered person's provider. For a noncertification, the insurer shall notify the covered person's provider and send written or electronic confirmation of the noncertification to the covered person. In concurrent reviews, the insurer shall remain liable for health care services until the covered person has been notified of the noncertification.

NCGS 58-50-61(g) Retrospective Reviews. – As used in this subsection, "necessary information" includes the results of any patient examination, clinical evaluation, or second opinion that may be required. For retrospective review determinations, an insurer shall make the determination within 30 days after receiving NC Dept. of Insurance 43 Market Regulation Division – Domestic Carriers Full Service January 2013 all necessary information. For a certification, the insurer may give written notification to the covered person's provider. For a noncertification, the insurer shall give written notification to the covered person and the covered person's provider within five business days after making the noncertification.

NCGS 58-50-61(h) Notice of Noncertification. – A written notification of a noncertification shall include all reasons for the noncertification, including the clinical rationale, the instructions for initiating a voluntary appeal or reconsideration of the noncertification, and the instructions for requesting a written statement of the clinical review criteria used to make the noncertification. An insurer shall provide the clinical review criteria used to make the noncertification to any person who received the notification of the noncertification and who follows the procedures for a request. An insurer shall also inform the covered person in writing about the availability of assistance from the Managed Care Patient Assistance Program, including the telephone number and address of the Program.

NCGS 58-50-61(i) Requests for Informal Reconsideration. – An insurer may establish procedures for informal reconsideration of noncertifications and, if established, the procedures shall be in writing. After a written notice of noncertification has been issued in accordance with subsection (h) of this section, the reconsideration shall be conducted between the covered person’s provider and a medical doctor licensed to practice medicine in this State designated by the insurer. An insurer shall not require a covered person to participate in an informal reconsideration before the covered person may appeal a noncertification under subsection (j) of this section. If, after informal reconsideration, the insurer upholds the noncertification decision, the insurer shall issue a new notice in accordance with subsection (h) of this section. If the insurer is unable to render an informal reconsideration decision within 10 business days after the date of receipt of the request for an informal reconsideration, it shall treat the request for informal reconsideration as a request for an appeal, provided that the requirements of subsection (k) of this section for acknowledging the request shall apply beginning on the day the insurer determines an informal reconsideration decision cannot be made before the tenth business day after receipt of the request for an informal reconsideration.

NCGS 58-50-61(j) Appeals of Noncertifications. – Every insurer shall have written procedures for appeals of noncertifications by covered persons or their providers acting on their behalves, including expedited review to address a situation where the time frames for the standard review procedures set forth in this section would reasonably appear to seriously jeopardize the life or health of a covered person or jeopardize the covered person's ability to regain maximum function. Each appeal shall be evaluated by a medical doctor licensed to practice medicine in this State who was not involved in the noncertification.

NCGS 58-50-61(k) Nonexpedited Appeals. – Within three business days after receiving a request for a standard, nonexpedited appeal, the insurer shall provide the covered person with the name, address, and telephone number of the coordinator and information on how to submit written material. For standard, nonexpedited appeals, the insurer shall give written notification of the decision, in clear terms, to the covered person and the covered person's provider within 30 days after the insurer receives the request for an appeal. If the decision is not in favor of the covered person, the written decision shall contain: (1) The professional qualifications and licensure of the person or persons reviewing the appeal. (2) A statement of the reviewers' understanding of the reason for the covered person's appeal. (3) The reviewers' decision in clear terms and the medical rationale in sufficient detail for the covered person to respond further to the insurer's position. (4) A reference to the evidence or documentation that is the basis for the decision, including the clinical review criteria used to make the determination, and instructions for requesting the clinical review criteria.

NC Dept. of Insurance 44 Market Regulation Division – Domestic Carriers Full Service January 2013 (5) A statement advising the covered person of the covered person's right to request a second-level grievance review and a description of the procedure for submitting a second-level grievance under G.S. 58-50-62. Note: the second-level process is addressed by NCGS 58-50-62, “Insurer Grievance Procedures” (6) Notice of the availability of assistance from the Managed Care Patient Assistance Program including the telephone number and address of the Program.

NCGS 58-50-61(l) Expedited Appeals. – An expedited appeal of a noncertification may be requested by a covered person or his or her provider acting on the covered person's behalf only when a nonexpedited appeal would reasonably appear to seriously jeopardize the life or health of a covered person or jeopardize the covered person's ability to regain maximum function. The insurer may require documentation of the medical justification for the expedited appeal. The insurer shall, in consultation with a medical doctor licensed to practice medicine in this State, provide expedited review, and the insurer shall communicate its decision in writing to the covered person and his or her provider as soon as possible, but not later than four days after receiving the information justifying expedited review. The written decision shall contain the provisions specified in subsection (k) of this section. If the expedited review is a concurrent review determination, the insurer shall remain liable for the coverage of health care services until the covered person has been notified of the determination. An insurer is not required to provide an expedited review for retrospective noncertifications.

NCGS 58-50-61(m) Disclosure Requirements. – In the certificate of coverage and member handbook provided to covered persons, an insurer shall include a clear and comprehensive description of its Utilization Review procedures, including the procedures for appealing noncertifications and a statement of the rights and responsibilities of covered persons, including the voluntary nature of the appeal process, with respect to those procedures. An insurer shall also include in the certificate of coverage and the member handbook information about the availability of assistance from the Managed Care Patient Assistance Program, including the telephone number and address of the Program. An insurer shall include a summary of its Utilization Review procedures in materials intended for prospective covered persons. An insurer shall print on its membership cards a toll-free telephone number to call for Utilization Review purposes.

NCGS 58-50-61(n) Maintenance of Records. – Every insurer and URO shall maintain records of each review performed and each appeal received or reviewed, as well as documentation sufficient to demonstrate compliance with this section. The maintenance of these records, including electronic reproduction and storage, shall be governed by rules adopted by the Commissioner that apply to insurers. These records shall be retained by the insurer and URO for a period of five years or until the Commissioner has adopted a final report of a general examination that contains a review of these records for that calendar year, whichever is later.

NCGS 58-50-61(o) Violation. – A violation of this section subjects an insurer to G.S. 58-2-70. (1997-443, s. 11A.122; 1997-519, s. 4.1; 1999-116, s. 1; 1999-391, ss. 1-4.)

NC Dept. of Insurance 45 Market Regulation Division – Domestic Carriers Full Service January 2013 MARKET REGULATION DIVISION C6b. Compliance Certification: Delegated External Review

Pursuant to NCGS 58-3-191 (“Managed Care Reporting and Disclosure Requirements”) and NCGS 58-50-77, 58-50-79, 58-50-80 and 58-50-82 (“External Review”), (“Insurer”), duly licensed and authorized to do business in the State of North Carolina, hereby provides notification that it has delegated External Review responsibilities to (“Delegated Entity”). Insurer certifies to the Commissioner of the North Carolina Department of Insurance that the Delegated Entity’s External Review program, and the Insurer’s oversight/monitoring of that program, is compliant with the Statutes listed and referenced below. Note: The actual documentation will be required at the Market Regulation Division’s next scheduled Market Conduct Examination of the Insurer or at the discretion of the Department.

NCGS 58 - 50 - 77 Notice of right to external review. (a) An insurer shall notify the covered person in writing of the covered person's right to request an external review and include the appropriate statements and information set forth in this section at the time the insurer sends written notice of: (1) A noncertification decision under G.S. 58-50-61; (2) An appeal decision under G.S. 58-50-61 upholding a noncertification; and (3) A second-level grievance review decision under G.S. 58-50-62 upholding the original noncertification. (b) The insurer shall include in the notice required under subsection (a) of this section for a notice related to a noncertification decision under G.S. 58-50-61, a statement informing the covered person that if the covered person has a medical condition where the time frame for completion of an expedited review of an appeal decision involving a noncertification decision under G.S. 58-50-61 would reasonably be expected to seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, then the covered person may file a request for an expedited external review under G.S. 58-50-82 at the same time the covered person files a request for an expedited review of an appeal involving a noncertification decision under G.S. 58-50-61, but that the Commissioner will determine whether the covered person shall be required to complete the expedited review of the grievance before conducting the expedited external review. (c) The insurer shall include in the notice required under subsection (a) of this section for a notice related to an appeal decision under G.S. 58-50-61, a statement informing the covered person that: (1) If the covered person has a medical condition where the time frame for completion of an expedited review of a grievance involving an appeal decision under G.S. 58-50-61 would reasonably be expected to seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, the covered person may file a request for an expedited external review under G.S. 58-50-82 at the same time the covered person files a request for an expedited review of a grievance involving an appeal decision under G.S. 58-50-62, but that the Commissioner will determine whether the covered person shall be required to complete the expedited review of the grievance before conducting the expedited external review. (2) If the covered person has not received a written decision from the insurer within 60 days after the date the covered person files the second- level grievance with the insurer pursuant to G.S. 58-50-62 and the covered person has not requested or agreed to a delay, the covered

NC Dept. of Insurance 46 Market Regulation Division – Domestic Carriers Full Service January 2013 person may file a request for external review under G.S. 58-50-80 and shall be considered to have exhausted the insurer's internal grievance process for purposes of G.S. 58-50-79. (d) The insurer shall include in the notice required under subsection (a) of this section for a notice related to a final second-level grievance review decision under G.S. 58-50-62, a statement informing the covered person that: (1) If the covered person has a medical condition where the time frame for completion of a standard external review under G.S. 58-50-80 would reasonably be expected to seriously jeopardize the life or health of the covered person or jeopardize the covered person's ability to regain maximum function, the covered person may file a request for an expedited external review under G.S. 58-50-82; or (2) If the second-level grievance review decision concerns an admission, availability of care, continued stay, or health care service for which the covered person received emergency services but has not been discharged from a facility, the covered person may request an expedited external review under G.S. 58-50-82. (e) In addition to the information to be provided under this section, the insurer shall include a copy of the description of both the standard and expedited external review procedures the insurer is required to provide under G.S. 58-50-93, including the provisions in the external review procedures that give the covered person the opportunity to submit additional information. (2001-446, s. 4.5.)

NCGS 58 - 50 - 80 Standard external review. (e) Failure by the insurer or its designee utilization review organization to provide the documents and information within the time specified in this subsection shall not delay the conduct of the external review. However, if the insurer or its utilization review organization fails to provide the documents and information within the time specified in subdivision (b)(4) of this section, the assigned NC Dept. of Insurance 47 Market Regulation Division – Domestic Carriers Full Service January 2013 organization may terminate the external review and make a decision to reverse the noncertification appeal decision or the second-level grievance review decision. Within one business day of making the decision under this subsection, the organization shall notify the covered person, the insurer, and the Commissioner. (g) Upon receipt of the information required to be forwarded under subsection (f) of this section, the insurer may reconsider its noncertification appeal decision or second-level grievance review decision that is the subject of the external review. Reconsideration by the insurer of its noncertification appeal decision or second-level grievance review decision under this subsection shall not delay or terminate the external review. The external review shall be terminated if the insurer decides, upon completion of its reconsideration, to reverse its noncertification appeal decision or second-level grievance review decision and provide coverage or payment for the requested health care service that is the subject of the noncertification appeal decision or second-level grievance review decision. (h) Upon making the decision to reverse its noncertification appeal decision or second-level grievance review decision under subsection (g) of this section, the insurer shall notify the covered person, the organization, and the Commissioner in writing of its decision. The organization shall terminate the external review upon receipt of the notice from the insurer sent under this subsection. (l) Upon receipt of a notice of a decision under subsection (k) of this section reversing the noncertification appeal decision or second-level grievance review decision, the insurer shall within three business days reverse the noncertification appeal decision or second-level grievance review decision that was the subject of the review and shall provide coverage or payment for the requested health care service or supply that was the subject of the noncertification appeal decision or second-level grievance review decision. In the event the covered person is no longer enrolled in the health benefit plan when the insurer receives notice of a decision under subsection (k) of this section reversing the noncertification appeal decision or second-level grievance review decision, the insurer that made the noncertification appeal decision or second-level grievance review decision shall be responsible under this section only for the costs of those services or supplies the covered person received or would have received prior to disenrollment if the service had not been denied when first requested.

NCGS 58 - 50 - 82 Expedited external review. (c) As soon as possible, but within the same business day of receiving notice under subdivision (b)(2) of this section that the request has been assigned to a review organization, the insurer or its designee utilization review organization shall provide or transmit all documents and information considered in making the noncertification appeal decision or the second-level grievance review decision to the assigned review organization electronically or by telephone or facsimile or any other available expeditious method. A copy of the same information shall be sent by the same means or other expeditious means to the covered person or the covered person's representative who made the request for expedited external review. (f) If the notice provided under subsection (e) of this section was not in writing, within two days after the date of providing that notice, the assigned organization shall provide written confirmation of the decision to the covered person, the covered person's provider who performed or requested the service, the insurer, and the Commissioner and include the information set forth in G.S. 58-50-80(m). Upon receipt of the notice of a decision under subsection (e) of this section that reverses the noncertification, noncertification appeal decision, or second-level grievance review decision, the insurer shall within one day reverse the noncertification, noncertification appeal decision, or second-level grievance review decision that was the subject of the review and shall provide coverage or payment for the requested health care service or supply that was the subject of the noncertification, noncertification appeal decision, or second-level grievance review decision.

NC Dept. of Insurance 48 Market Regulation Division – Domestic Carriers Full Service January 2013 NC Dept. of Insurance 49 Market Regulation Division – Domestic Carriers Full Service January 2013 II. Monitoring Activities IMPORTANT NOTE: Answer the following questions applicable to Data Year 2012

To demonstrate compliance with NCGS 58-3-191 and NCGS 58-50-61, Insurers who delegate Utilization Review programs must provide requested information within the text boxes below. Do not attach any additional documentation.

To demonstrate compliance with NCGS 58-3-191 and NCGS 58-50-77, NCGS 58-50-79, NCGS 58-50-80 and NCGS 58-50-82, Insurers who delegate External Review programs must provide requested information within the text boxes below. Do not attach any additional documentation.

Delegated Review Entity:

Check all type(s) of Reviews the Delegated Entity conducts on services provided to NC insureds: Utilization Review: Prospective Concurrent Retrospective Informal Reconsideration Noncert Appeals – 1st Level Noncert Appeals – 2nd Level External Review

Check all type(s) of Utilization Review notifications developed and mailed by the Delegated Entity to NC insureds: Utilization Review: Prospective Concurrent Retrospective Informal Reconsideration Noncert Appeals – 1st Level Noncert Appeals – 2nd Level External Review

Question 1: Identify each version of the Delegated Entity’s Utilization Review Program - Policies & Procedures (P&Ps) including related form/template letters effective during the specified data year.

Answer 1:

NC Dept. of Insurance 50 Market Regulation Division – Domestic Carriers Full Service January 2013 Question 2: Does the Delegated Entity’s Utilization Review Program - Policies & Procedures (P&Ps) include mental health/chemical dependency and/or pharmacy benefit programs? If not, be sure to separately identify each of these policies.

Answer 2:

Question 3: Identify each version of the Insurer’s internal Policies & Procedures (P&Ps) for oversight of the Delegated Entity’s Utilization Review program effective during the specified data year.

Answer 3:

Question 4: Does the Insurer’s oversight Policies & Procedures (P&Ps) include mental health/chemical dependency and/or pharmacy benefit programs? If not, be sure to separately identify each of these policies.

Answer 4:

Question 5: When did the Insurer complete its most recent review of the Delegated Entity’s Utilization Review program – Policies & Procedures (P&Ps)? (Must specify month/year)

Answer 5:

Question 6: When does the Insurer anticipate conducting its next review of the Delegated Entity’s Utilization Review program – Policies & Procedures (P&Ps)? (Must specify month/year)

Answer 6:

Question 7: On what date did the Insurer complete its most recent review of the Delegated Entity’s UR related form/template letters as referenced in NCGS 58-50-61, NCGS 58-50-77, 58-50-79, 58- 50-80 and 58-50-82? (Must specify month/year)

Answer 7:

NC Dept. of Insurance 51 Market Regulation Division – Domestic Carriers Full Service January 2013 Question 8: On what date did the Insurer complete its most recent audit sampling of the Delegated Entity’s UR related correspondence as referenced in NCGS 58-50-61, NCGS 58-50-77, 58-50-79, 58-50-80 and 58-50-82? (Must specify month/year)

Answer 8:

Question 9: Specify the number of cases reviewed. (Applicable to Question/Answer #8)

Answer 9:

Answer 10:

Question 11: Were all the Delegated Entity’s case correspondence compliant (language and time requirements) with State law and did they include External Review Rights when required? If not explain all deficiencies found, along with corrective actions taken and/or planned.

Answer 11:

Question 12: Identify areas of non-compliance in the Policies & Procedures (P&Ps) including related form/template letters, along with corrective actions taken and/or planned.

Answer 12:

Question 13: What is/are the position title(s) and clinical degree(s) of the Insurer’s staff who have ultimate oversight responsibility for the Delegated Entity’s Utilization Review program (If more than one person, clarify the duties for each)?

Answer 13:

Question 14: What is/are the position title(s) and clinical degree(s) of the Delegated Entity’s staff who have ultimate operational responsibility of the Delegated Entity’s Utilization Review program (If more than one person, clarify the duties for each)?

Answer 14:

Question 15: What is/are the position title(s) and clinical degree(s) of the Delegated Entity’s staff who have ultimate oversight responsibility of the Delegated Entity’s Utilization Review program (If more than one person, clarify the duties for each)?

Question 16: Provide the following information regarding the individual(s) making noncertification decisions: (Insert additional lines as necessary)

*Note if the Insurer uses an outside organization please properly identify the organization and list those individual(s) within the organization making noncertification decisions. If additional space is needed, an attachment may be used.

Answer 16:

Name: Clinical Degree: State(s) where clinical degree/license is active and in good standing:

NC Dept. of Insurance 53 Market Regulation Division – Domestic Carriers Full Service January 2013 MARKET REGULATION DIVISION C7. Compliance Certification: Intermediary Arrangements Submit one Certification for each subcontracted Intermediary.

Pursuant to 11 NCAC 20.0204 (“Carrier and Intermediary Contracts”), (“Carrier”), duly licensed and authorized to do business in the State of North Carolina, hereby provides notification that it has entered into a subcontractual relationship with (“Intermediary”). Carrier certifies to the Commissioner of the North Carolina Department of Insurance that the Carrier’s contract with the Intermediary, and the Intermediary’s own program, are fully compliant with all of the Regulations listed and referenced below. Note: The actual documentation will be required at the Market Regulation Division’s next scheduled Market Conduct Examination of the Insurer or at the discretion of the Department.

I. Applicable Regulations

11 NCAC 20.0204 Carrier and Intermediary Contracts. (a) If a Carrier contracts with an intermediary for the provision of a network to deliver health care services, the Carrier shall file with the Division for prior approval its form contract with the intermediary. The filing shall be accompanied by a certification from the Carrier that the intermediary will, by the terms of the contract, be required to comply with all statutory and regulatory requirements which apply to the functions delegated. The certification shall also state that the Carrier shall monitor such compliance. (b) A Carrier's contract form with the intermediary shall state that: (1) All provider contracts used by the intermediary shall comply with, and include applicable provisions of 11 NCAC 20.0202. (2) The network Carrier retains its legal responsibility to monitor and oversee the offering of services to its members and financial responsibility to its members. (3) The intermediary may not subcontract for its service without the Carrier's written permission. (4) The Carrier may approve or disapprove participation of individual providers contracting with the intermediary for inclusion in or removal from the Carrier's own network plan. (5) The Carrier shall retain copies or the intermediary shall make available for review by the Department all provider contracts and subcontracts held by the intermediary. (6) If the intermediary organization assumes risk from the Carrier or pays its providers on a risk basis or is responsible for claims payment to it providers: (A) The Carrier shall receive documentation of utilization and claims payment and maintain accounting systems and records necessary to support the arrangement. (B) The Carrier shall arrange for financial protection of itself and its members through such approaches as member hold harmless language, retention of signatory control of the funds to be disbursed or financial reporting requirements. (C) To the extent provided by law, the Department shall have access to the books, records, and financial information to examine activities performed by the intermediary on behalf of the Carrier. Such books and records shall be maintained in the State of North Carolina. (7) The intermediary shall comply with all applicable statutory and regulatory requirements that apply to the functions delegated by the Carrier and assumed by the intermediary. (c) If a Carrier contracts with an intermediary to provide health care services and pays that intermediary directly for the services provided, the Carrier shall either monitor the financial condition of the

NC Dept. of Insurance 54 Market Regulation Division – Domestic Carriers Full Service January 2013 intermediary to ensure that providers are paid for services, or maintain member hold harmless agreements with providers.

11 NCAC 20.0202 Contract Provisions. All contract forms that are created or amended on or after the effective date of this Section, and all contract forms that are executed later than six (6) months after the effective date of this Section, shall contain provisions addressing the following: (1) Whether the contract and any attached or incorporated amendments, exhibits, or appendices constitute the entire contract between the parties. (2) Definitions of technical insurance or managed care terms used in the contract, and whether those definitions reference other documents distributed to providers and are consistent with definitions included in the evidence of coverage issued in conjunction with the network plan. (3) An indication of the term of the contract. (4) Any requirements for written notice of termination and each party's grounds for termination. (5) The provider's continuing obligations after termination of the provider contract or in the case of the Carrier or intermediary insolvency. The obligations shall address: (a) Transition of administrative duties and records. (b) Continuation of care, when inpatient care is on-going. If the Carrier provides or arranges for the delivery of health care services on a prepaid basis, inpatient care shall be continued until the patient is ready for discharge. (6) The provider's obligation to maintain licensure, accreditation, and credentials sufficient to meet the Carrier's credential verification program requirements and to notify the Carrier of subsequent changes in status of any information relating to the provider's professional credentials. (7) The provider's obligation to maintain professional liability insurance coverage in an amount acceptable to the Carrier and notify the Carrier of subsequent changes in status of professional liability insurance on a timely basis. (8) With respect to member billing: (a) If the Carrier provides or arranges for the delivery of health care services on a prepaid basis under G.S. 58, Article 67, the provider shall not bill any network plan member for covered services, except for specified coinsurance, copayments, and applicable deductibles. This provision shall not prohibit a provider and member from agreeing to continue noncovered services at the member’s own expense, as long as the provider has notified the member in advance that the Carrier may not cover or continue to cover specific services and the member chooses to receive the service. (b) Any provider's responsibility to collect applicable member deductibles, copayments, coinsurance, and fees for noncovered services shall be specified. (9) Any provider's obligation to arrange for call coverage or other back-up to provide service in accordance with the Carrier's standards for provider accessibility. (10) The Carrier's obligation to provide a mechanism that allows providers to verify member eligibility, based on current information held by the Carrier, before rendering health care services. Mutually agreeable provision may be made for cases where incorrect or retroactive information was submitted by employer groups. (11) Provider requirements regarding patients' records. The provider shall: (a) Maintain confidentiality of enrollee medical records and personal information as required by G.S. 58, Article 39 and other health records as required by law. (b) Maintain adequate medical and other health records according to industry and Carrier standards. (c) Make copies of such records available to the Carrier and Department in conjunction with its regulation of the Carrier. (12) The provider's obligation to cooperate with members in member grievance procedures. NC Dept. of Insurance 55 Market Regulation Division – Domestic Carriers Full Service January 2013 (13) A provision that the provider shall not discriminate against members on the basis of race, color, national origin, gender, age, religion, marital status, health status, or health insurance coverage. (14) Provider payment that describes the methodology to be used as a basis for payment to the provider (for example, Medicare DRG reimbursement, discounted fee for service, withhold arrangement, HMO provider capitation, or capitation with bonus). (15) The Carrier's obligations to provide data and information to the provider, such as: (a) Performance feedback reports or information to the provider, if compensation is related to efficiency criteria. (b) Information on benefit exclusions; administrative and utilization management requirements; credential verification programs; quality assessment programs; and provider sanction policies. Notification of changes in these requirements shall also be provided by the Carrier, allowing providers time to comply with such changes. (16) The provider's obligations to comply with the Carrier's utilization management programs, credential verification programs, quality management programs, and provider sanctions programs with the provision that none of these shall override the professional or ethical responsibility of the provider or interfere with the provider's ability to provide information or assistance to their patients. (17) The provider's authorization and the Carrier's obligation to include the name of the provider or the provider group in the provider directory distributed to its members. (18) Any process to be followed to resolve contractual differences between the Carrier and the provider. (19) Provisions on assignment of the contract shall contain: (a) The provider's duties and obligations under the contract shall not be assigned, delegated, or transferred without the prior written consent of the Carrier. (b) The Carrier shall notify the provider, in writing, of any duties or obligations that are to be delegated or transferred, before the delegation or transfer.

11 NCAC 20.0201 Written Contracts. (a) All contracts between network plan carriers and health care providers and between network plan carriers and intermediary organizations offering networks of health care providers to be used by network plan carriers for the provision of care on a preferred or in-network basis shall be in writing and shall comply with 11 NCAC 20 .0202 as a condition of such health care providers' and networks' being listed in the carrier's provider directory. (b) The form of every contract under Paragraph (a) of this Rule shall be filed with the Division for approval according to these Rules before it is used. (c) As used in this Section and in Section .0600 of this Chapter, "Division" means the Life and Health Division of the Department of Insurance.

11 NCAC 20.0203 Changes Requiring Approval. All material changes to an approved contract form shall be filed with the Division for approval before use. For the purpose of this Section, a "material change" includes a change in the means of calculating payment to the provider (for example, change from fee for service to capitation), a change in the distribution of risk between parties, or a change in the delegation of clinical or administrative responsibilities.

NCGS 58 - 50 - 270 Definitions. Unless the context clearly requires otherwise, the following definitions apply in this Part. (1) "Amendment" – Any change to the terms of a contract, including terms incorporated by reference, that modifies fee schedules. A change required by federal or State law, rule, regulation, administrative hearing, or court order is not an amendment. (2) "Contract" – An agreement between an insurer and a health care provider for the provision of health care services by the provider on a preferred or in-network basis. NC Dept. of Insurance 56 Market Regulation Division – Domestic Carriers Full Service January 2013 (3) "Health benefit plan" – A policy, certificate, contract, or plan as defined in G.S. 58-3-167. (3a)"Health care provider" – An individual who is licensed, certified, or otherwise authorized under Chapter 90 or Chapter 90B of the General Statutes or under the laws of another state to provide health care services in the ordinary course of business or practice of a profession or in an approved education or training program and a facility that is licensed under Chapter 131E or Chapter 122C of the General Statutes or is owned or operated by the State of North Carolina in which health care services are provided to patients. (4) "Insurer" – An entity as defined in G.S. 58-3-227(a)(4). (2009-352, s. 1; 2009-487, s. 2(a).)

NCGS 58 - 50 - 275 Notice contact provisions. (a) All contracts shall contain a "notice contact" provision listing the name or title and address of the person to whom all correspondence, including proposed amendments and other notices, pertaining to the contractual relationship between parties shall be provided. Each party to a contract shall designate its notice contact under such contract. (b) Means for sending all notices provided under a contract shall be one or more of the following, calculated as (i) five business days following the date the notice is placed, first-class postage prepaid, in the United States mail; (ii) on the day the notice is hand delivered; (iii) for certified or registered mail, the date on the return receipt; or (iv) for commercial courier service, the date of delivery. Nothing in this section prohibits the use of an electronic medium for a communication other than an amendment if agreed to by the insurer and the provider. (2009-352, s. 1; 2009-487, s. 2(b).)

NCGS 58 - 50 - 280 Contract amendments. (a) A health benefit plan or insurer shall send any proposed contract amendment to the notice contact of a health care provider pursuant to G.S. 58-50-275. The proposed amendment shall be dated, labeled "Amendment," signed by the health benefit plan or insurer, and include an effective date for the proposed amendment. (b) A health care provider receiving a proposed amendment shall be given at least 60 days from the date of receipt to object to the proposed amendment. The proposed amendment shall be effective upon the health care provider failing to object in writing within 60 days. (c) If a health care provider objects to a proposed amendment, then the proposed amendment is not effective and the initiating health benefit plan or insurer shall be entitled to terminate the contract upon 60 days written notice to the health care provider. (d) Nothing in this Part prohibits a health care provider and insurer from negotiating contract terms that provide for mutual consent to an amendment, a process for reaching mutual consent, or alternative notice contacts. (2009-352, s. 1; 2009-487, s. 2(c).)

NCGS 58 - 50 - 285 Policies and procedures. (a) A health benefit plan or insurer shall provide a copy of its policies and procedures to a health care provider prior to execution of a new or amended contract and annually to all contracted health care providers. Such policies and procedures may be provided to the health care provider in hard copy, CD, or other electronic format, and may also be provided by posting the policies and procedures on the Web site of the health plan or insurer. (b) The policies and procedures of a health benefit plan or insurer shall not conflict with or override any term of a contract, including contract fee schedules. In the event of a conflict between a policy or procedure and the language in a contract, the contract language shall prevail. (2009-352, s. 1.)

To demonstrate compliance with 11 NCAC 20.0201, 20.0202, 20.0203 and 11 NCAC 20.0204, Carriers with Intermediary arrangements must provide requested information within the text boxes below for each contracted Intermediary.

To demonstrate compliance with NCGS 58-50- 275, NCGS 58-50-280 and NCGS 58-50-285, Carriers with Intermediary arrangements must provide requested information within the text boxes below for each contracted Intermediary.

Intermediary:

Identify ALL entities subcontracted by the above Intermediary:

Question 1: Identify each version of the Insurer’s internal Policies & Procedures (P&Ps) for oversight of the Intermediary’s delegated activities other than Grievance, Utilization Review and Provider Availability/Accessibility effective during the specified data year.

Answer 1:

Question 2: When did the Carrier complete its most recent review of the Intermediary’s provider contract form/template? (Must specify month/year)

Answer 2:

Question 3: When did the Carrier complete its most recent audit sampling of the Intermediary’s executed provider contracts? (Must specify month/year)

Answer 3:

Question 4: When does the Carrier anticipate conducting its next review of the Intermediary’s provider contract form/template and audit sampling of executed provider contracts? (Must specify month/year)

Answer 4:

NC Dept. of Insurance 58 Market Regulation Division – Domestic Carriers Full Service January 2013 Question 5: Specify the number of the Intermediary’s executed provider contracts reviewed by the Carrier.

Answer 5:

Question 6: If a subcontracted Intermediary was utilized, which organization conducted the oversight of the subcontracted Intermediary’s Policies & Procedures (P&Ps), provider contract form/template and executed provider contracts (Company/Intermediary and Name/Title)?

How many executed provider contracts were reviewed for compliance and when was the review date (month/year)?

Answer 6:

Question 7: How (method of communication) and when was the Carrier notified of the oversight findings of the subcontracted Intermediary?

Answer 7:

Question 8: What was the Company’s rationale in determining the number of executed provider contracts reviewed as referenced? (Applicable to Questions/Answers #5 and #6)

Answer 8:

Question 9: Identify areas of non-compliance identified in the provider contract template(s), along with corrective actions taken and/or planned. (Applicable to Questions/Answers #2 and #6)

Answer 9:

Question 10: Identify all deficiencies found in the audit samplings of the executed provider contracts, along with corrective actions taken and/or planned. (Applicable to Questions/Answers #5 and #6)

Answer 10:

Question 11: Identify the form number(s) of the provider contract template(s) reviewed for compliance. The form number is located in the lower left corner of the contract. (Applicable to Questions/Answers #2 and #6)

Answer 11:

NC Dept. of Insurance 59 Market Regulation Division – Domestic Carriers Full Service January 2013 Question 12: Were any material changes as defined by 11 NCAC 20.0203 made to any of the executed provider contracts reviewed in the Insurer’s audit sampling? If “yes”, please provide the SERFF tracking number for the filing of the revised provider contract. (Applicable to Questions/Answers #5 and #6). If no SERFF tracking number is available, an explanation must be provided.

Answer 12:

Question 13: Were any material changes as defined by 11 NCAC 20.0203 made to the contract between the Carrier and Intermediary? If “yes”, please provide the approval date and SERFF tracking number of the Life & Health filing. If no SERFF tracking number is available, an explanation must be provided.

Answer 13:

Question 14: If the Intermediary paid claims, did the Intermediary hold an active and valid TPA license for the specified data year? For any questions or concerns regarding this subject please contact our Life & Health Division for guidance.

Answer 14:

Question 15: If the Carrier pays the Intermediary directly for the services provided, does the Carrier have in place financial protection for itself and its members through member hold harmless language? If no, please explain.

Answer 15:

NC Dept. of Insurance 60 Market Regulation Division – Domestic Carriers Full Service January 2013 MARKET REGULATION DIVISION C8. Compliance Certification: Provider Availability and Accessibility

Pursuant to NCGS 58-3-191 (“Managed Care Reporting and Disclosure Reporting Requirements”), 11 NCAC 20.0301 (“Provider Availability Standards”), 11 NCAC 20.0302 (“Provider Accessibility Standards”), and 11 NCAC 20.0304 (“Monitoring Activities”) (“Insurer”), duly licensed and authorized to do business in the State of North Carolina, certifies to the Commissioner of the North Carolina Department of Insurance that its program is fully compliant with all of the Regulations listed and referenced below.

If applicable, the Carrier hereby provides notification that it has entered into a subcontractual relationship with (“Intermediary”) to provide network services utilizing standards and methodology defined by the Carrier. Carrier certifies to the Commissioner of the North Carolina Department of Insurance that the Carrier’s contract with the Intermediary, and the Intermediary’s own program, are fully compliant with all of the Regulations listed and referenced below. Note: The actual documentation will be required at the Market Regulation Division’s next scheduled Market Conduct Examination of the Insurer or at the discretion of the Department.

11 NCAC 20.0301 Provider Availability Standards. Each network plan carrier shall develop a methodology to determine the size and adequacy of the provider network necessary to serve the members. The methodology shall provide for the development of performance targets that shall address the following: (1) The number and type of primary care physicians, specialty care providers, hospitals, and other provider facilities, as defined by the Carrier. (2) A method to determine when the addition of providers to the network will be necessary based on increases in the membership of the network plan Carrier. (3) A method for arranging or providing health care services outside of the service area when providers are not available in the area.

11 NCAC 20.0302 Provider Accessibility Standards. Each Carrier shall establish performance targets for member accessibility to primary and specialty care physician services and hospital based services. Carriers shall also establish similar performance targets for health care services provided by providers who are not physicians. Written policies and performance targets shall address the following: (1) The proximity of network providers as measured by such means as driving distance or time a member must travel to obtain primary care, specialty care and hospital services, taking into account local variations in the supply of providers and geographic considerations. (2) The availability to provide emergency services on a 24-hour, seven day per week basis. (3) Emergency provisions within and outside of the service area. (4) The average or expected waiting time for urgent, routine, and specialist appointments.

11 NCAC 20.0304 Monitoring Activities. Each Carrier shall, by means of site visits or review of information gathered by the Carrier, monitor compliance with this Section and evaluate provider availability and accessibility at least annually to ensure that the needs of its members are met. Supporting documentation of these activities shall be maintained for a period of five years or until the completion of the next triennial examination conducted by the Department, whichever is later. NC Dept. of Insurance 61 Market Regulation Division – Domestic Carriers Full Service January 2013 II. Monitoring Activities IMPORTANT NOTE: Answer the following questions applicable to Data Year 2012

To demonstrate compliance with 11 NCAC 20.0301, 20.0302 and 20.0304, Carriers with their own provider networks or who require its subcontracted Intermediaries to utilize Carrier’s provider accessibility and availability standards must provide requested information within the text boxes below. Do not attach additional documentation.

Intermediary:

Question 1: Check which standard(s) were established by the Plan. DO NOT DISCLOSE THE ACTUAL STANDARDS.

Answer 1:

Network Density Driving Distance Appointment Wait Times

Question 2: Identify each version of the Carrier’s Policies & Procedures (P&Ps) for provider availability and accessibility effective during the specified data year.

Answer 2:

Question 3: When did the Carrier complete its most recent review of its own Policies & Procedures (P&Ps) regarding provider availability and accessibility? (Must specify month/year)

Answer 3:

Question 4: When does the Carrier anticipate conducting its next review of its own Policies & Procedures (P&Ps) regarding provider availability and accessibility? (Must specify month/year)

Answer 4:

Question 5: Is the Carrier monitoring the provider availability/accessibility according to the terms and frequency of the established Policies & Procedures (P&Ps)?

Answer 5:

Question 6: Identify areas of non-compliance in the Carrier’s Policies & Procedures (P&Ps), along with corrective actions taken and/or planned.

Answer 6:

Question 7: Identify what information (report) was reviewed by the Carrier to determine if the network density standards for the specified data year were met. This information/report must support the reported results.

Answer 7:

Question 8: Specify the date of the report, the time period covered by the report and when the Carrier reviewed this information (report) on network density standards and actual results.

Answer 8:

Question 9: Identify network density standard which was not met and explain what, if any, corrective active was taken and/or planned.

Answer 9:

Question 10: Identify what information (report) was reviewed by the Carrier to determine if the driving distance standards for the specified data year were met. This information/report must support the reported results.

Answer 10:

Question 11: Specify the date of the report, the time period the covered by the report and when the Carrier reviewed this information (report) on driving distance standards and actual results.

Answer 11:

Question 12: Identify any driving distance standard which was not met and explain what, if any, corrective active was taken and/or planned.

Answer 12:

Question 13: Specify if a NC member or NC provider survey was used in determining appointment wait time results.

Question 14: Specify the date of the survey, the time period the survey covered and when the Carrier reviewed the survey results on appointment wait times standards.

Answer 14:

Question 15: Disclose the participation rate (# of members/providers surveyed vs. # of respondents).

Answer 15:

Question 16: Identify any supplemental method used to measure any appointment wait times type (i.e. reviewing complaints/grievance when not enough responses were received for a valid survey or cold calls to providers offices’ to measure compliance with contractual emergency provisions to measure emergency appointment wait times).

Answer 16:

Question 17: Identify any appointment wait times standard which was not met and explain what, if any, corrective active was taken and/or planned.

Answer 17:

Question 18: Was any standard revised for this reporting year? If “yes”, state the change, the reason for the change and the date when the change was approved by the Carrier.

Answer 18:

Question 19: State the Carrier or Intermediary’s policy for paying claims for in-network emergency care? Is prior authorization required?

Answer 19:

Question 20: State the Carrier or Intermediary’s policy for paying claims for out-of-network emergency care? Is prior authorization required?

Answer 20:

NC Dept. of Insurance 64 Market Regulation Division – Domestic Carriers Full Service January 2013 Question 21: What provisions (authorization and claim payment) are made for members when care by a participating provider cannot be provided within the availability and accessibility standards and a member seeks care from a non-participating provider? (This includes those counties with membership but no or limited providers.)

Is prior authorization required? Does the member have to file a grievance for reimbursement? Is the member balance billed?

Answer 21:

Question 22: Describe the Carrier’s disclosure provisions to members about receiving care from a non-participating provider when an in-network provider is not reasonably available (within the standards for driving distance and/or appointment wait times).

Identify the document used during the reporting period which discloses these provisions (i.e. member handbook, enrollment material, Certificate, etc.)

Answer 22:

Question 23: If the above Intermediary used a subcontracted entity (as identified in the C7 Certification) and its provider network was used to supplement the Plan’s or Intermediary’s network (not a standalone network option) were the Company’s answers and provider availability/accessibility results inclusive of ALL participating providers? If “no”, an explanation must be provided.

Answer 23:

NC Dept. of Insurance 65 Market Regulation Division – Domestic Carriers Full Service January 2013 MARKET REGULATION DIVISION C9. Compliance Certification: Delegated Provider Availability and Accessibility Submit one Certification for each subcontracted Intermediary.

Pursuant to NCGS 58-3-191 (“Managed Care Reporting and Disclosure Reporting Requirements”), 11 NCAC 20.0301 (“Provider Availability Standards”), 11 NCAC 20.0302 (“Provider Accessibility Standards”), and 11 NCAC 20.0304 (“Monitoring Activities”) (“Carrier”), duly licensed and authorized to do business in the State of North Carolina, hereby provides notification that it has entered into a subcontractual relationship with (“Intermediary”). Carrier certifies to the Commissioner of the North Carolina Department of Insurance that the Carrier’s contract with the Intermediary, and the Intermediary’s own program, are fully compliant with all of the Regulations listed and referenced below. Note: The actual documentation will be required at the Market Regulation Division’s next scheduled Market Conduct Examination of the Insurer or at the discretion of the Department.

11 NCAC 20.0301 Provider Availability Standards. Each network plan carrier shall develop a methodology to determine the size and adequacy of the provider network necessary to serve the members. The methodology shall provide for the development of performance targets that shall address the following: (1) The number and type of primary care physicians, specialty care providers, hospitals, and other provider facilities, as defined by the Carrier. (2) A method to determine when the addition of providers to the network will be necessary based on increases in the membership of the network plan Carrier. (3) A method for arranging or providing health care services outside of the service area when providers are not available in the area.

11 NCAC 20.0302 Provider Accessibility Standards. Each Carrier shall establish performance targets for member accessibility to primary and specialty care physician services and hospital based services. Carriers shall also establish similar performance targets for health care services provided by providers who are not physicians. Written policies and performance targets shall address the following: (1) The proximity of network providers as measured by such means as driving distance or time a member must travel to obtain primary care, specialty care and hospital services, taking into account local variations in the supply of providers and geographic considerations. (2) The availability to provide emergency services on a 24-hour, seven day per week basis. (3) Emergency provisions within and outside of the service area. (4) The average or expected waiting time for urgent, routine, and specialist appointments.

11 NCAC 20.0304 Monitoring Activities. Each Carrier shall, by means of site visits or review of information gathered by the Carrier, monitor compliance with this Section and evaluate provider availability and accessibility at least annually to ensure that the needs of its members are met. Supporting documentation of these activities shall be maintained for a period of five years or until the completion of the next triennial examination conducted by the Department, whichever is later.

To demonstrate compliance with 11 NCAC 20.0301, 20.0302 and 20.0304, Carriers with Intermediary arrangements must provide requested information within the text boxes below for each contracted Intermediary. Do not attach additional documentation.

Intermediary:

Question 1: Check which standard(s) were established by the Intermediary. DO NOT DISCLOSE THE ACTUAL STANDARDS.

Answer 1:

Network Density Driving Distance Appointment Wait Times

Question 2: Identify each version of the Insurer’s internal Policies & Procedures (P&Ps) for oversight of the Intermediary’s provider availability and accessibility effective during the specified data year.

Answer 2:

Question 3: Identify each version of the Intermediary’s Policies & Procedures (P&Ps) for provider availability and accessibility effective during the specified data year.

Answer 3:

NC Dept. of Insurance 67 Market Regulation Division – Domestic Carriers Full Service January 2013 Question 4: When did the Carrier complete its most recent review of the Intermediary’s Policies & Procedures (P&Ps) regarding provider availability and accessibility? (Must specify month/year)

Answer 4:

Question 5: When does the Carrier anticipate conducting its next review of the Intermediary’s Policies & Procedures (P&Ps) regarding provider availability and accessibility? (Must specify month/year)

Answer 5:

Question 6: Is the Intermediary monitoring the provider availability/accessibility according to the terms and frequency of the established Policies & Procedures (P&Ps)?

Answer 6:

Question 7: Identify areas of non-compliance in the Intermediary’s Policies & Procedures (P&Ps), along with corrective actions taken and/or planned.

Answer 7:

Question 8: Identify what information (report) was reviewed by the Carrier to determine if the network density standards for the specified data year were met. This information/report must support the reported results.

Answer 8:

Question 9: Specify the date of the report, the time period covered by the report and when the Carrier reviewed this information (report) on network density standards and actual results.

Answer 9:

Question 10: Identify any network density standard which was not met and explain what, if any, corrective active was taken and/or planned.

Answer 10:

Question 11: Identify what information (report) was reviewed by the Carrier to determine if the driving distance standards for the specified data year were met. This information/report must support the reported results.

Question 12: Specify the date of the report, the time period covered by the report and when the Carrier reviewed this information (report) on driving distance standards and actual results.

Answer 12:

Question 13: Identify any driving distance standard which was not met and explain what, if any, corrective active was taken and/or planned.

Answer 13:

Question 14: Specify if a NC member or NC provider survey was used in determining appointment wait time results.

Answer 14:

Question 15: Specify the date of the survey, report, the time period the survey covered and when the Carrier reviewed this information (report) on appointment wait times standards.

Answer 15:

Question 16: Describe the participation rate (# of members/providers surveyed vs. # of respondents).

Answer 16:

Question 17: Identify any supplemental method used to measure any appointment wait times type (i.e. reviewing complaints/grievance when not enough responses were received for a valid survey or cold calls to providers offices’ to measure compliance with contractual emergency provisions to measure emergency appointment wait times).

Answer 17:

Question 18: Identify any appointment wait times standard which was not met and explain what, if any, corrective active was taken and/or planned.

Answer 18:

NC Dept. of Insurance 69 Market Regulation Division – Domestic Carriers Full Service January 2013 Question 19: Was any standard revised for this reporting year? If “yes”, state the change, the reason for the change and the date when the change was discussed/approved by Carrier.

Answer 19:

Question 20: State the Carrier or Intermediary’s policy for paying claims for in-network emergency care? Is prior authorization required?

Answer 20:

Question 21: State the Carrier or Intermediary’s policy for paying claims for out-of-network emergency care? Is prior authorization required?

Answer 21:

Question 22: What provisions (authorization and claim payment) are made for members when care by a participating provider cannot be provided within the availability and accessibility standards and a member seeks care from a non-participating provider? (This includes those counties with membership but no or limited providers.)

Is prior authorization required? Does the member have to file a grievance for reimbursement? Is the member balance billed?

Answer 22:

Question 23: Describe the Carrier’s disclosure provisions to members about receiving care from a non-participating provider when an in-network provider is not reasonably available (within the standards for driving distance and/or appointment wait times).

Identify the document used during the reporting period which disclosures these provisions (i.e. member and book, enrollment material, Certificate, etc.)

Answer 23:

Question 24: If the above Intermediary used a subcontracted entity (as identified in the C7 Certification) and its provider network was used to supplement the Plan’s or Intermediary’s network (not a standalone network option) were the Company’s answers and provider

NC Dept. of Insurance 70 Market Regulation Division – Domestic Carriers Full Service January 2013 availability/accessibility results inclusive of ALL participating providers? If “No”, an explanation must be provided.

Answer 24: