Appeals: Plans/issuers are required to have an internal appeals process (compliant with existing Department of Labor [DOL] requirements) that allows enrollees to review their files, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process. Notice of the appeals process is required to be provided to enrollees in a culturally and linguistically appropriate manner.
External review: Plans/issuers must also have an external review process. The requirements of the external review process are dependent upon whether a plan is subject to the “state standard” or the “federal standard” under the interim final regulations.
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