Claims Appeals and Reviews

Government Resources
Analysis 

Government Resources

Internal Claims and Appeals and External Review Processes

The CCIIO has released a fact sheet entitled, External Appeals: Preliminary Determinations of External Appeals Review Processes. 8/3/11  

The EBSA and HHS issued amendments to the Interim Final Rules implementing the requirements regarding internal claims and appeals and external review processes for group health plans and health insurance coverage in the group and individual markets under provisions of the ACA. These rules are intended to respond to feedback from stakeholders on the interim final regulations and to assist plans and issuers in coming into full compliance with the law through an orderly implementation process. The amendments focus primarily on six issues: 

• Expedited notification of benefit determinations involving urgent care
• Additional notice requirements with respect to notice of adverse benefit
  determinations or final internal adverse benefit determination
• Deemed exhaustion of internal claims and appeals processes
• Providing notices in a culturally and linguistically appropriate manner
• Duration of transition period for State external review processes
• Scope of the Federal External Review Process 

Public comments on the amendment to the regulations are requested and must be submitted on or before July 25, 2011. The agencies also released additional guidance and revised model notices related to the amended interim final rules.

• Public Comments on the Amendment to Interim Final Rule – Internal Claims and Appeals and External Review Processes, 9/7/11  
• Technical Corrections to Amendments to the Interim Final Rule, 7/26/11  
• Amendments to the Interim Final Rule, 6/24/11  
• Technical Release 2011-02, 6/22/11    
• Revised Model Notice of Adverse Benefit Determination, 6/22/11    
• Revised Model Notice of Final Internal Adverse Benefit Determination, 6/22/11    
• Revised Model Notice of Final External Review Decision, 6/22/11    
• Updated List of Consumer Assistance Programs, as of 5/23/11,

The EBSA issued Technical Release 2011-01 modifying and extending the enforcement grace period set forth in Technical Release 2010-02 until plan years beginning on or after January 1, 2012. Technical Release 2011-01 is to act as a bridge until the final regulations relating to certain claims and appeals procedures under the Affordable Care Act (ACA) can be released. 3/18/11  

The agencies have released a request for information (RFI) to gain market analysis information in advance of one or more future Requests for Proposals (RFP). This RFI solicits information that will enable the HHS and the DOL to conduct a market analysis and assist the Departments in planning and developing the federal external review process. Comments may be submitted through December 8, 2010. 11/15/10 

The agencies have issued Technical Release 2010-02 which sets forth an enforcement grace period until July 1, 2011 for compliance with certain new provisions with respect to internal claims and appeals. 9/20/10 
 
The OCIIO has released additional guidance on the external review process required by ACA.

• Technical Guidance on the Interim Federal External Appeals Process, 9/1/10 
• Notice of Privacy Act Rights Statement for Issuers in States without External Review Laws, 9/1/10 
• Guidance on the Culturally and Linguistically Appropriate Standards, 9/1/10 

On August 23, 2010, the EBSA, IRS and OCIIO released additional guidance and model forms related to the rules on claims, appeals and external reviews for nongrandfathered health plans.

• Interim Procedures of Federal External Review, 8/26/10 
• Technical Release 2010-01, 8/23/10 
• Revised Model Notice of Adverse Benefit Determination, 9/20/10 
  • Spanish version
• Model Notice of Final External Review Decision, 8/23/10
  • Spanish version 
• Model Notice of Final Internal Adverse Benefit Determination, 8/23/10 
• Spanish version 

On July 22, 2010, the EBSA, IRS and OCIIO released interim final regulations implementing rules on internal claims and appeals and external review processes for new (nongrandfathered) health plans.

• Interim Final Regulations, 7/22/10 
• News Release, 7/22/10  
• Fact Sheet, 7/22/10 
• NAIC Uniform External Review Model Act, 7/22/10
• Public Comments 

Analysis  

• Internal Claims and Appeals and External Review Under Health Care Reform, Groom Law, 9/7/11  
• So What Are My Internal and External Claim Review Requirements? A Question Every Group Health Plan Is Asking., Alston & Bird, 8/23/11  
• DOL, HHS, and Treasury Issue Amended Guidance on Health Care Reform’s Internal and External Claims Process Rules, Buck Consultants, 8/4/11    
• DOL, HHS, and IRS Issue Amendments to Rules Relating to Internal Claims and Appeals and External Review Processes under the Affordable Care Act, Mintz Levin, 7/19/11  
• Health Care Reform: Summary of Amended Regulations on Claims and Appeal Procedures for Group Health Plans, Davis Wright Tremaine, 7/14/11 
  Additional Guidance Released on Internal Claims and Appeals and External Review Processes, McGuire Woods, 7/7/11  
• New Guidance and Transitional Relief for PPACA Claims and External Review Procedures, Pillsbury Winthrop Shaw Pittman, 7/7/11  
• Amendment to Affordable Care Act's Claims and Appeals Rules, Groom Law Group, 7/6/11  
• Changes to PPACA Claims and External Review Rules Include More Transition Relief, Sutherland Asbill & Brennan, 6/29/11  
• Agencies Release Amended Procedures for Internal Claims and Appeals and External Review, Aon Hewitt, 6/24/11  
• HHS Scales Back Rules on Health Insurance Appeals, Kaiser Health News, 6/23/11
• Benefits Claims, Appeals and External Review Timeline for Non-Grandfathered Self-Insured Group Health Plans, Kelly Hannaford & Battles, 4/26/11  
• Government Extends Enforcement Grace Period for Certain of the Internal Health Claims and Appeals Requirements, Buck Consultants, 4/12/11 
• Department of Labor Extends Enforcement Grace Period for Certain Internal Claims and Appeals Requirements, Alston Bird, 4/7/11  
• Departments Extend Grace Period for Compliance with New Claims Process Rules, McGuire Woods, 3/31/11  
• Extension of Enforcement Grace Period for Internal Claims and Appeals under ACA, Proskauer Rose, 3/30/11  
• Enforcement Dates Extended for PPACA Internal Appeals Procedures, Mintz Levin, 3/29/11  
• Health Care Reform: Another Extended Grace Period, Venable, 3/29/11  
• Cafeteria plans, HRAs and External Appeals Requirements, Wolter Kluwer, 3/23/11  
• DOL Extends Enforcement Grace Period for Certain Internal Claims and Appeals Procedures, Aon Hewitt, 3/22/11
• New Group Health Plan Internal Claims and Appeals and External Review Procedures Created by PPACA, Alston & Bird, 9/22/10 
• Health Care Reform: Claims and Appeals Procedures, Thompson Hine, 9/10/10 
• HHS Issues Guidance on Federal External Review Process for Fully Insured Group Health Plans, Hewitt, 9/2/10 
• Additional Guidance Issued on Appeals and External Review Processes, Buck Consultants, 9/1/10   
• Model Notices to Comply with PPACA's Claims and Appeals Regulation and Interim Guidance on the Federal External Review Process, Groom Law Group, 8/25/10 
• Health Care Reform: Internal Claims and Appeals and External Review Process, Reinhart Boerner Van Deuren, 8/25/10 
• Agencies Release Interim Procedures for Federal External Review and Model Notices, Hewitt, 8/24/10   
• Claims and Appeals Procedures: New Internal and External Review Requirements, Jones Day, 8/24/10 
• Health Care Reform: New Guidance on Claims and Appeals Procedures for Group Health Plans, Davis Wright Tremaine, 8/23/10
• New Health Care Claims and Appeal Rules Will Include a Tax Bite. Littler Mendelson, 8/16/10 
• Internal and External Claims Review Guidance for Non-Grandfathered Health Plans Released, Buck Consultants, 8/11/10 
• PPACA Appeal Process Changes – Interim Final Rule, Groom Law Group, 7/28/10   
• PPACA Rules for Internal Claims and Appeals and External Review Processes, PricewaterhouseCoopers, 7/27/10 
• Agencies Release Interim Final Rule on Claims and Appeals and External Review Processes, Hewitt, 7/23/10