PART II. INTERNAL CLAIMS AND APPEALS PROCESS
§2401. Requirements of federal laws and regulations; minimum requirements
Health insurance issuers shall implement effective processes for appeals of coverage determinations and claims pursuant to Section 2719 of the Public Health Service Act (42 U.S.C. 300gg-19) and any federal regulations promulgated pursuant thereto by the United States Department of Labor and the United States Department of Health and Human Services. Under such processes, a health insurance issuer shall, at a minimum:
(1) Have in effect an internal claims appeal process.
(2) Provide notice to covered persons, in a culturally and linguistically appropriate manner, of available internal and external appeals processes and the availability of the office of consumer advocacy of the Department of Insurance to assist such persons with the appeals process.
(3) Allow covered persons, upon request and free of charge, to review and have copies of all documents relevant to the claim for benefits and to submit comments and documents relating to the claim, without regard to whether that information was submitted or considered in the initial benefit determination, and to receive continued coverage pending the outcome of the appeals process where required by applicable law or the plan document or policy.
Acts 2013, No. 326, §1, eff. Jan. 1, 2015.
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