The procedures for handling patient complaints about major medical plan coverage decisions continue to differ from state to state. Officials at the Center for Consumer Information and Insurance Oversight (CCIIO) explain where patients should send requests for outside decision reviews in a new guide aimed at people who help consumers use commercial health insurance coverage.
The Centers for Medicare & Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services (HHS), set up CCIIO to oversee day-to-day implementation of the parts of the Patient Protection and Affordable Care Act of 2010 (PPACA) that affect commercial health insurance.
State regulators, federal regulators and members of Congress began drafting health coverage appeals and external review rules long before President Obama signed PPACA into law.
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The Obama administration is still using an interim final rule published in 2010 to regulate the appeal and review system, and, up until now, news about the birth of the PPACA public exchange system has mostly overshadowed news about the appeal and review system.
CCIIO officials note in the new guide that insurers themselves handle claims and internal appeals. Outside entities handle external reviews of the insurers’ coverage decisions.