Keenan Briefings

Briefings

HCR: Self-Insured Government Plans - New Information for Claims Denials

July 24, 2019

Under the Affordable Care Act, participants and beneficiaries have rights to appeal health plan decisions to deny payment for services or coverage of treatment for some claims. Under the law, most health plans must meet basic standards for how to handle internal appeals and external reviews.

Non-grandfathered self-insured government plans that use the Department of Health and Human Services (HHS)-administered Federal External Review Process must update their notices to inform participants and beneficiaries of the options for requesting an external review (i.e. via email, mail, fax or through the online portal).

Not all self-insured government plans use this process. Some self-insured government plans use the Federal External Review Process whereby a plan has directly or indirectly contracted with three Independent Review Organizations (IROs) to review external appeals. This Briefing does not apply to plans that use the non-HHS-administered Federal External review Process.

The HHS-administered Federal External Review Process is available for adverse benefit determinations and final internal adverse benefit determination that involve medical judgment (i.e. medical necessity, appropriateness, health care setting, level of care or effectiveness of a covered benefit); a determination that a treatment is experimental or investigational; a determination whether a participant or beneficiary is entitled to a reasonable alternative standard for a reward under a wellness program; or a determination whether a plan is complying with the nonquantitative treatment limitations provisions of the Mental Health Parity and Addiction Equity Act, such as medical management techniques, and any rescission of coverage.

In Department of Health and Human Services Update to Technical Guidance-01-2018, dated July 12, 2019, plans that use the HHS-administered Federal External Review Process must include a notice in any adverse benefit determination or final internal adverse benefit determination to a claimant that the claimant can request an external review by submitting the request:

  • online at https://externalappeal.cms.gov, under the “Request a Review Online” heading; or
  • in writing by faxing the request to 1.888.866.6190; or
  • by sending it by mail to:

    MAXIMUS Federal Services
    3750 Monroe Avenue, Suite 705
    Pittsfield, NY 14534

The notice must inform the claimant that if they believe the review should be expedited, they can select “expedited” if submitting the review online, or by emailing FERP@maximus.com, or calling Federal External Review Process at 888.866.6205 ext. 3326.

Samples of updated notices must be provided electronically to externalappeals@cms.hhs.gov.

The Update to Technical Guidance can be found at this link.

Please contact your Keenan Account Manager for questions regarding this Briefing.


Keenan & Associates is not a law firm and no opinion, suggestion, or recommendation of the firm or its employees shall constitute legal advice. Clients are advised to consult with their own attorney for a determination of their legal rights, responsibilities and liabilities, including the interpretation of any statute or regulation, or its application to the clients’ business activities.