PPACA: Internal Claims and Appeals and External Review Part II

The interim final rules published by the HHS, DOL and the IRS provided details regarding the external review requirements under the Patient Protection Affordable Care Act (PPACA). Group health plans and insurers must comply with the external review processes under the regulations. A group health plan not subject to state external review processes is required under the PPACA to comply with the federal external review process. The regulations that are currently available do not fully address what it means to have a compliant federal external review process. The agencies have stated that the standards for the federal external review process will be based on NAIC Uniform Model Act. Group health plans and insurers subject to these new regulations should carefully review their current internal claims and appeals procedures. If a group health plan or insurer is subject to a state external review process, then the plan or insurer must verify its procedures are compliant. A plan or insurer required to comply with the new federal external review process will have to wait for those federal requirements to be issued. In the meantime, the DOL and IRS issued Technical Release 2010-01 that provides an interim safe harbor for all plans subject to the federal review process. What we do know is that like much, if not all, of the PPACA, these new internal claims and appeals and external review requirements will continue to add to the already existing administrative burdens placed on plan sponsors. The Kaufman & Canoles Health Care Practice Group will continue to monitor these regulations as further guidance is issued on the federal external review process. –Katie G. Davenport