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Health Care Reform Website

Claims & Appeals

The Affordable Care Act (ACA) imposed new claims and appeals requirements on non-grandfathered plans for plan years beginning on or after September 23, 2010.For fully-insured plans, the carrier has primary responsibility to administer and comply with the requirements. Self-funded sponsors are subject to these requirements as well but their third party administrator will usually administer the provisions as part of their normal claims operations.

Internal Review Process

The ACA requirements are aimed at making the review process simpler and more responsive to consumers. One way this is achieved is by creating standardized time frames for the handling of claims. Consumers must also be allowed to review the claim file, present evidence and give testimony as part of the process.

External Review Process

The external review process is available for claims that involve medical judgment and rescissions.  Any other type of claim is ineligible for external review.

Additional Information

Appeals Procedures – Regulations Issued
     This Briefing outlines regulatory guidance with respect to appeals procedures under the ACA.

Implementation Guidance Claims and Appeals Procedures
     This Briefing outlines implementation guidance with respect to the claims and appeals procedures.

Updated Guidance Claims and Appeals – Non-Grandfathered Plans
     This Briefing updates and supplements earlier Briefings and identifies important information for nonfederal government plans.

Governmental Plans – Claims and Appeals – New HHS Election/Update Model Notice
     On June 15, 2015, new instructions were issued regarding the notification process to elect the Federal External Review Process or update previously submitted information. This Briefing describes the method that must be used to inform HHS about the election or submit updated information.