New Hampshire covers dental denials too, and gives you 180 days

Health or dental, and free

New Hampshire sets three conditions for a standard external review, and the second of them is the one that surprises people: the plan must be a fully insured health OR DENTAL insurance plan. Dental coverage is inside the scheme rather than an afterthought.

• A fully insured health or dental insurance plan.
• The insurer's internal appeal process completed.
• A final denial of services from the insurer.
• There is no cost to the patient for an external review.

180 days, and up to 60 for the answer

The request goes to the Insurance Department within 180 days of the insurer's final denial — half again as long as the federal four-month standard — and the independent review organization may take up to 60 days to reach its decision.

What the review is for

External review is available where a recommended service or treatment was denied on the basis that it does not meet the insurer's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness. That is the clinical-judgement family of denials; a flat contractual exclusion is a different argument.

The expedited track, and who opens it

For an expedited external review the plan must again be fully insured health or dental, and the treating provider must certify that delaying treatment will seriously jeopardise the life or health of the patient, or will jeopardise their ability to regain maximum function. Independent review organizations must complete expedited reviews within 72 hours.

How to file

1. 1

   Complete the internal appeal

   Eligibility requires the insurer's internal appeal process to be finished and a final denial issued.

2. 2

   Submit to the Insurance Department

   The standard external review is submitted to the Department within 180 days of the final denial.

3. 3

   Add the provider certification if urgent

   Only the treating provider's certification opens the 72-hour expedited track.

4. 4

   Expect up to 60 days on the standard track

   The review organization may take that long to decide a standard case.

Retroactive denials, and the codes a recoupment must carry

New Hampshire is unusually precise about clawbacks, and the detail is directly usable by a billing office. RSA 420-J:8-b prohibits retroactive denial of a previously paid claim unless the carrier gives the provider a written explanation and acts within 12 months of the original payment date. The Insurance Department's guidance goes further on what that explanation has to contain.

• At least 15 days' advance written notice before any recoupment is initiated.
• Enough detail for the provider to understand the rationale and make corrections — a generalised 'an adjustment has been made' does not meet the standard.
• The appropriate federal Claim Adjustment Reason Codes and Remittance Advice Remark Codes must be included; pharmacy claims must also carry the NCPDP denial reason codes.
• Beyond 12 months only in defined situations: fraud, duplicate payment, services not delivered by the provider, services covered by Medicare or Medicaid, or a claim subject to adjustment with a different insurer.

For New Hampshire practices

Two habits follow. Do not exclude dental denials from the escalation path here — a fully insured dental plan is eligible on the same terms as a health plan, which is unusual enough that it gets missed. And note that the Insurance Department has issued guidance on retroactive denial of health claims, which is the right starting point when the dispute is about a claim reversed after payment rather than one refused up front.

Every medical-necessity call, under a medical director

New Hampshire attaches the requirement to the carrier, whoever actually performs the work. RSA 420-J:6 requires a carrier conducting utilization review — directly or through a contracted review entity — to ensure that every medical necessity determination is made by a qualified health care provider.

The reviewing provider must hold medical and professional expertise and credentials appropriate to applying the carrier's clinical review criteria competently, and must decide under the clinical direction of a medical director of the carrier or of the contracted entity who is responsible for reviewing services furnished to covered persons resident in New Hampshire. RSA 420-J:3 completes the chain: a medical director must be a physician licensed under RSA 329 and employed by the carrier or the review entity. Outsourcing the review does not relocate the obligation.