2 AAC 39.620. Appeal to plan administrator

(a) An enrollee may appeal to the plan administrator from a final decision by the claims payer denying the enrollee's claim in whole or in part. A "final decision by the claims payer" is a decision that is not subject to any further review by the claims payer.

(b) The enrollee's appeal must be in writing, must explain the grounds for the appeal, and must be postmarked or received by the plan administrator within 45 days of the date that the enrollee received written notice of the final decision by the claims payer. The appellant may submit documentation in support of the appeal. The filing requirement of this subsection may be waived by the plan administrator if the enrollee can show that there are extraordinary circumstances resulting in the enrollee's inability to meet the filing requirement.

(c) The plan administrator shall send a final written decision on the appeal within 30 days of the date that the appeal is received, unless the administrator determines that additional information is necessary for resolution of the appeal. If the administrator determines that additional information is necessary from the appellant, the administrator shall allow the appellant an additional 30 days to submit the additional information. If the additional information is not furnished within 30 days, the administrator may deny the appeal. If the additional information is furnished in a timely manner, the administrator shall send a final written decision on the appeal within 30 days of the date that the additional information is received. If the plan administrator determines that a medical review by an independent review organization is necessary, the administrator shall make such request and notify the appellant within 15 days of the date that the appeal is received. After the plan administrator receives the report of the independent review, the administrator shall send a final written decision on the appeal within 30 days of the date that the independent review is received.

(d) In the final written decision, the plan administrator shall indicate which aspects of the decision are appealable to the board under 2 AAC 39.630, and which aspects are not so appealable.

History: Eff. 5/27/99, Register 151

Authority: AS 14.25.035

AS 14.25.168

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