(1) Any person who is aggrieved by a decision of the Commission, or by a final decision of one of the Commission's self-insured plan administrators about benefits may appeal in writing to the Commission's Executive Director. Benefits that are explicitly excluded from coverage in the plan of benefits are not appealable. The Executive Director shall consult with the Commission's General Counsel to determine whether the matter warrants presentment to the Commission's Appeals Committee. If presentment is warranted, the Executive Director shall enter the matter on the Commission's Appeals Docket for resolution via the Commission's appeals procedures. The Appeals Committee's decisions are final and binding, and may only be re-considered if new information that was unknowable at the time of the initial appeal to the Appeals Committee would alter the outcome of the appeal. Appellants may append their appeals to the Commission up to a maximum of 120 days after their initial filing in order to obtain additional information. Appeals that exceed the 120 day period will be closed without prejudice to the appellant.
(2) Notwithstanding clause (1), the Executive Director may modify appeals procedures in order to achieve compliance with requirements of federal law, including but not limited to 42 U.S.C. § 300gg–19. To that end, Commission’s Executive Director may delegate external appeals procedures to the Commission’s self-insured plan administrators. If the Executive Director has delegated appeals procedures to one or more plan administrators, any person who is aggrieved by a decision of the Commission, or by a final decision of one of the Commission's self-insured plan administrators about benefits, may appeal in writing to the plan administrator.
(3) Notwithstanding clauses (1) and (2), eligibility decisions by the Commission are final and not subject to appeal procedures under this section.
This information provided by the Group Insurance Commission .
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