CHAPTER 18.  INTERNAL CLAIMS AND APPEALS PROCESS

AND EXTERNAL REVIEW ACT

PART I.  TITLE, DEFINITIONS, AND LICENSURE

§2391.  Purpose; short title

A.  This Chapter shall be known and may be cited as the "Internal Claims and Appeals Process and External Review Act".

B.  The purpose of this Chapter is the following:

(1)  To establish standards and criteria for the structure and operation of utilization review and benefit determination processes designed to facilitate ongoing assessment and management of health care services.

(2)  To provide standards for the establishment and maintenance of procedures by health insurance issuers to assure that covered persons have the opportunity for the appropriate resolution of internal and external appeals, as defined in this Chapter.

(3)  To provide uniform standards for the establishment and maintenance of an internal claims and appeals process and external review procedures to assure that covered persons have the opportunity for an independent review of an adverse determination or final adverse determination, as defined in this Chapter.

Acts 2013, No. 326, §1, eff. Jan. 1, 2015.