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. The processes shall comply with any applicable federal law or regulation. 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; Acts 2020, No. 36, §1.