1. (1) The purpose of this rule is to provide a uniform standard for the establishment and maintenance of an:

   1. (a) independent review procedure to assure that a claimant has the opportunity for an independent review of a final adverse benefit determination; and
   2. (b) external review of a non-formulary drug under 45 CFR 156.122.

2. (2)(a) This rule applies to a carrier offering a health benefit plan.

   1. (b) This rule does not apply to a:

      1. (i) grandfathered health benefit plan; or
      2. (ii) transitional health benefit plan.
   2. (c) If all grandfathered health benefit plans are administered consistently, a carrier may voluntarily comply with the independent review process outlined in this rule.
   3. (d) A self-funded health plan may voluntarily comply with the independent review process outlined in this rule.

KEY: health benefit plan insurance

Date of Last Change: August 27, 2025

Notice of Continuation: May 19, 2026

Authorizing, and Implemented or Interpreted Law: 31A-22-629; 31A-2-201; 31A-2-212