HHS Issues Technical Guidance for Self-Insured Health Plans on Federal External Review Process

​The Department of Health and Human Services (HHS) issued technical guidance on standards for self-insured non-federal governmental health plans and health insurance issuers offering group and individual health coverage that are subject to the HHS-administered federal external review process under section 2719(b)(2) of the Public Health Service (PHS) Act. The technical release replaces the technical guidance issued June 22, 2011 with standards adopted in the final regulation at 76 FR 37208 that further define requirements under PHS Act section 2719(b)(1).

Section 2719(b)(1) of the PHS Act requires that non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual coverage comply with the applicable State external review process in their State if that process includes, at a minimum, the consumer protections set forth in the Uniform External Review Model Act issued by the National Association of Insurance Commissioners  and is binding on the plan or issuer. If the State external review process does not meet this standard, or if the plan or issuer is not subject to State insurance regulation, section 2719(b)(2) of the PHS Act provides that group health plans and health insurance issuers shall implement an effective external review process that meets minimum standards established by the Secretary through guidance and that is similar to a State external review process that meets the standards in section 2719(b)(1) of the PHS Act. The regulations at 45 CFR 147.136(d) describe a process for meeting this requirement, referred to as the Federal external review process.

Insured coverage not subject to an applicable State external review process under 45 CFR 147.136(c) and self-insured non-Federal governmental plans may elect to use the Federal Independent Review Organization external review process as set forth in 45 CFR 147.136(d)(2) or the HHS-administered Federal external review process as set forth in 45 CFR 147.136(d)(4) and outlined in the technical guidance.

Notice of Privacy Act Rights for external review process