Section R2-6-401. Appeal of a Plan-provider Decision

A.      The Department has delegated to each plan provider the authority to:

1.        Interpret and apply the terms of the plan provider’s par- ticular insurance plan;

2.        Determine whether a particular benefit is included in the plan and, if included, the amount of payment to be made under the plan; and

3.        Perform a full and fair review of any decision by the plan provider regarding benefits included in or payments to be made under the plan if the decision is appealed in accor- dance with the plan provider’s specified procedures.

B.       An individual who is enrolled in an insurance plan made avail- able by the Department and who wishes to appeal a decision by the plan provider shall follow the appeal procedures speci- fied in the applicable plan description.

Historical Note

Adopted effective July 27, 1983 (Supp. 83-4). Section repealed, new Section adopted effective September 16, 1997 (Supp. 97-3). Section expired under A.R.S. § 41-

1056(E) at 8 A.A.R. 5017, effective September 30, 2002 (Supp. 02-4). New Section made by final rulemaking at 15 A.A.R. 258, effective March 7, 2009 (Supp. 09-1).