The Affordable Care Act is presenting employers with new challenges in managing benefit plans. The information in this section will help you stay informed about how to adequately administer your plans.

Claims and Appeals

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The Affordable Care Act (ACA) imposes new claims and appeals requirements on non-grandfathered plans for plan years beginning on or after September 23, 2010. The aim of these requirements is to increase consumer protection by ensuring that plan participants have the opportunity to challenge a plan’s refusal to pay for a treatment or service.

For fully-insured plans, the insurance carrier has primary responsibility to administer and comply with these regulations.  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 health care 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.

During the review process, consumers must be provided with any new or additional evidence used by the plan in connection with the claim and any new rationale for determinations must also be explained.  This information must be provided for free and far enough in advance of the final internal appeal so the claimant has a reasonable opportunity to respond.  Whether or not a plan asserts it has complied with the requirements of the internal review process, a claimant may initiate an external review.

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
Health Care Reform: Appeals Procedures – Regulations Issues
This Briefing outlines regulatory guidance with respect to appeals procedures under the ACA.
Health Care Reform: Implementation Guidance Claims and Appeals Procedures
This Briefing outlines implementation guidance with respect to the claims and appeals procedures under the ACA.
Health Care Reform: Updated Guidance Claims and Appeals – Non-Grandfathered Plans
This Briefing updates and supplements earlier Briefings and identifies important information for nonfederal government plans.
Health Care Reform: 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.