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Health reform rules clarify appeals process


WASHINGTON—Interim final rules describing the appeals process and external claims review that non-grandfathered self-insured group health plans must follow under the health care reform law have been issued by the Departments of Labor, Health and Human Services and the Internal Revenue Service.

The rules clarify certain issues that were not addressed in previous regulations.

The Patient Protection and Affordable Care Act mandates that employees in self-funded health plans be able to request a “federal external review” of coverage if a claim or benefit is denied through internal reviews conducted by employers and plan administrators.

Under the interim final rules, which were issued Monday and apply to plan years beginning on or after Sept. 23, 2010, a group health plan must give claimants up to four months to request an external review after an adverse claim or benefit decision. A preliminary review of that request must be conducted within five business days of the receipt of that request, and the plan must issue a written notification to the claimant within one business day after the preliminary review has been completed.

If the preliminary review finds the need for an external review, the request must be referred to an independent review organization accredited by URAC or a similar nationally recognized accrediting organization. To ensure there is no bias in the external review process, benefit plans are required to contract with at least three of these independent review organizations and rotate claims assignments among them. In addition, the review organizations cannot be eligible for any financial incentives based on the likelihood that they would support denial of benefits.

An expedited external review process is prescribed for situations requiring immediate medical care, including urgent care and for those in which denial of payment for treatment would jeopardize the claimant's ability to regain maximum function.

The interim final rules also outline specific requirements that group benefit plans must include in their contracts with independent review organizations, as well as the type of information and documents that the review organizations must consider in making decisions.

Interested parties are encouraged to submit comments either in writing or via e-mail to the Labor Department regarding these interim final rules. Written comments should be mailed to the U.S. Department of Labor, Office of the Chief Information Officer, Attention: Departmental Clearance Officer, 200 Constitution Avenue N.C., Room N-1301, Washington, D.C. 20210 or via e-mail at and reference the OMB Control Number 120-0144.

Questions concerning the rules may be directed to the Office of Health Plan Standards and Compliance Assistance at 202-693-8335.

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