Health plan enrollees could soon be getting an automatic right to send internal health plan appeal denials to
New interim final rules governing group health plan and health insurer internal claims and appeals and external review processes were released today by the U.S. Department of Health and Human Services (HHS), the U.S. Labor Department and the U.S. Treasury Department.
Provisions in the new Affordable Care Act (ACA), the legislative package that includes the Patient Protection and Affordable Care Act (PPACA), set minimum standards for consumers’ ability to appeal claim denials, rescissions of coverage and other adverse decisions.
In the past, some states did not have external review requirements. Now, in all states, consumers who disagree with the results of in-plan appeals can submit disputes to independent reviewers.
Under the terms of the new regulations, which are set to take effect in policy or plan years starting on or after Sept. 23, health plans must have an internal appeals process that:
- Lets consumers appeal when a health plan denies a claim for a covered service or rescinds coverage.
- Gives consumers detailed information about the grounds for the denial of claims or coverage.
- Requires plans to notify consumers about their right to appeal and instructs them on how to begin the appeals process.
- Ensures a full and fair review of the denial.
- Provides consumers with an expedited appeals process in urgent cases.
If a patient’s internal appeal is denied, the patient will then be allowed to appeal to a reviewer that is not employed by their health plan or insurer.
The regulations will not apply to the “grandfathered plans” that were in effect March 23, officials say. The regulations will apply to insured and self-insured plans started or substantially changed after the March 23 cut-off..
The affected group plans and health insurers must pay for the external reviews.
The regulations do not appear to include a provision referring to consumers who file frivolous, unjustified or repeated appeals or requests for external reviews. Plans cannot charge more than $25 for an external review filing fee, and they cannot charge a consumer more than $75 per year for external review filing fees.
States cannot set review standards that are looser than the new federal standards, but they can set stricter standards.