NAIC Task Force Endorses External Health Review Model

By Jim Connolly

March 17, 2008 at 01:35 PM

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A panel at the National Association of Insurance Commissioners has given its blessing to a model act that would establish uniform standards for external health insurance review procedures.

The regulatory framework task force at the NAIC, Kansas City, Mo., has approved a draft of the Uniform Health Carriers External Review model act and sent it up to the NAIC's Health Insurance and Managed Care Committee.

The committee is expected to consider the draft at the NAIC's spring meeting, which is set to start March 28 in Orlando, Fla.

The model would apply to systems for reviewing adverse determinations and final adverse determinations affecting individuals covered by health insurance.

The model would exempt specified disease, specified accident and accident-only policies.

The model also would exempt public insurance programs and credit, dental, disability income, hospital indemnity, long term care, vision care, limited benefit and Medicare supplement insurance plans.

The model includes:

- A requirement that the carrier notify the covered individual in writing of the right to request an external review.

- A provision giving the individual a right to an expedited review if an individual has a medical condition that would "seriously jeopardize" the individual or the individual's potential recovery.

- A requirement that the covered individual exhaust the carrier's internal grievance process.

If a health carrier failed to respond in writing to a grievance within 30 days of the filing of the grievance, an external reviewer could assume the individual had exhausted the internal grievance process.

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