CHAPTER 27-38.2
Insurance Coverage for Mental Illness and Substance Abuse

SECTION 27-38.2-3

§ 27-38.2-3. Medical necessity and appropriateness of treatment.

(a) Upon request of the reimbursing health insurers, all providers of treatment of mental illness shall furnish medical records or other necessary data which substantiates that initial or continued treatment is at all times medically necessary and appropriate. When the provider cannot establish the medical necessity and/or appropriateness of the treatment modality being provided, neither the health insurer nor the patient shall be obligated to reimburse for that period or type of care that was not established. The exception to the preceding can only be made if the patient has been informed of the provisions of this subsection and has agreed in writing to continue to receive treatment at his or her own expense.

(b) The health insurers, when making the determination of medically necessary and appropriate treatment, must do so in a manner consistent with that used to make the determination for the treatment of other diseases or injuries covered under the health insurance policy or agreement.

(c) Any subscriber who is aggrieved by a denial of benefits provided under this chapter may appeal a denial in accordance with the rules and regulations promulgated by the department of health pursuant to chapter 17.12 of title 23.

History of Section.
(P.L. 1994, ch. 225, § 1; P.L. 1994, ch. 336, § 1; P.L. 1999, ch. 148, § 1; P.L. 2001, ch. 174, § 2; P.L. 2001, ch. 409, § 2; P.L. 2008, ch. 475, § 93.)