02-031 C.M.R. ch. 850, § 3 - Applicability and Scope
A. This rule shall
apply to all health carriers, utilization review organizations and managed care
plans as applicable. Section
7 is applicable to any carrier
offering a managed care plan. Section
8 is applicable to any carrier that
provides or performs utilization review services, any designee of the carrier
or utilization review entity (URE) that performs utilization review functions
on the carrier's behalf, and any URE performing utilization review on behalf of
an employer. The requirements of section
8 are also applicable to all "adverse
health care treatment decisions" rendered by or on behalf of "carriers"
offering "health plans," as defined by
24-A M.R.S.A.
§4301-A subsections
1,
3
and
7.
Sections
9 and
10 are applicable to all carriers.
The relationship of the appeals processes set forth in subsections
8(G) and
8 (G-1) to the grievance review
procedures of section
9 is as follows. All adverse health
care treatment decisions denying benefits to a covered person are subject to
the appeals procedures set forth in subsections
8(G) and
8 (G-1). All requests for review of
"adverse benefit determinations," other than "adverse health care treatment
decisions," are subject to the grievance review procedures set forth in section
9. In the event of conflict between
the provisions of this rule and those of any other rule promulgated by the
Superintendent, the provisions of this rule shall be controlling. Any request
for confidential handling of filings required by this rule must follow the
confidentiality protocol established by the Superintendent and available from
the Bureau of Insurance.
B. All
group and individual health plans under which covered services are subject to
utilization review, pre-existing condition determinations, or determinations
regarding experimental or investigational services, are subject to the
disclosure requirements of subsection
8(I).
C. All group and individual health plan
contracts must incorporate the appeal and grievance procedure description
required by subsection
10(B).
Notes
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