R590-261-2. Purpose and Scope

(1) The purpose of this rule is to provide a uniform standard for the establishment and maintenance of an: (a) independent review procedure to assure that a claimant has the opportunity for an independent review of a final adverse benefit determination; and (b) external review of a non-formulary drug under 45 CFR 156.122. (2)(a) This rule applies to a carrier offering a health benefit plan. (b) This rule does not apply to a: (i) grandfathered health benefit plan; or (ii) transitional health benefit plan. (c) If all grandfathered health benefit plans are administered consistently, a carrier may voluntarily comply with the independent review process outlined in this rule. (d) A self-funded health plan may voluntarily comply with the independent review process outlined in this rule.