IFEBP > ACA University > Health Plan Design > Claims Appeals and Reviews

Claims Appeals and Reviews

The Affordable Care Act (ACA) imposed new internal claims and appeals and external appeals processes for group health plans. Requirements generally apply to insured and self-insured group health plans, but not grandfathered plans.

Articles

Coverage Provisions In The 2021 Appropriations And COVID-19 Stimulus Package, Health Affairs, 1/4/2021

Major Employee Benefits Timeframe Extensions Announced for COVID-19 National Emergency, ABD Insurance & Financial Services, 4/29/2020

Government Resources

Grandfathered Plans, Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, Dependent Coverage, Appeals, and Patient Protections, CMS, EBSA, HHS, IRS, 11/18/2015 Final rules make no major changes from the interim rules but incorporate FAQ and other informal guidance since 2010, applicable January 1, 2017.

Internal Claims and Appeals and External Review Processes, IRS, EBSA, HHS, 6/24/2011 Amendments to interim final rule include time limit for urgent claims, diagnosis and treatment codes eliminated from notice

FAQs About ACA Implementation Part I, EBSA, 9/20/2010 Grandfathered health plans including multiemployer plan employer contribution rate, definition of dependent child, internal appeals and external review, out-of-network emergency services and balance billing

Internal Claims and Appeals and External Review Processes, IRS, EBSA, HHS, 7/23/2010 Interim final rules incorporate ERISA claims review rules with added internal appeal procedures, claimant rights, mandatory external review of many denied claims, information that notices of adverse benefit determinations must include