Appeals of Claims and Coverage
- Any group health plan, group or individual insurance issuer shall implement an effective process for determinations of claims and claims appeals (pp 36, lines 19- 23).
- Minimally the issuer or health plan shall provide an internal claims process.
- Notify enrollees using culturally and linguistically appropriate manners about the availability of internal and external appeals systems, also the availability of any applicable ombudsman or consumer assistance to help enrollees with appeals (pp 37, lines 1 – 7).
- Give enrollees the ability to review their “file,” to give testimony, and present evidence during the the appeals process. And, to continue to receive coverage while the outcome of the appeals process is pending (pp 37, lines 8 – 12).
- Have a provision for external review of appeals, including the rules established in the Uniform External Review Model Act circulated by the National association of Insurance Commissioners. These rules are to be binding in such plans (pp 37, lines 12-17).
Healthcare Reform summaries based on the original text of the Patient Protection and Affordable Care Act (Passed by the US Senate 12-24-09. Passed by the US House of Representatives 3-21-10. This summary is for informational purposes only. Actual provisions and any amended portions of the bills apply).