New Guidance Issued on Streamlined Insurance Appeal Process

by Rebecca Farley on September 9, 2010

The Department of Health and Human Services in July issued an interim final rule (IFR) providing for a streamlined process by which individuals can appeal insurance company decisions about their coverage, including both an internal claims and appeals and an external review process. While most states and insurance plans already have such processes in place, there is great variation in these plans. These regulations attempt to establish a baseline of consumer protections for healthcare beneficiaries in the private sector.

Under the new rules, new health plans beginning on or after September 23, 2010 must have an internal appeals process that allows consumers to appeal when a health plan denies a claim for a covered service or rescinds coverage. Plans must clearly explain to consumers the grounds for any denial, including the medical necessity criteria used. The rules also call for states to adopt specified standards for external review processes. HHS has issued a fact sheet explaining the IFR in greater detail.

The National Council has drafted comments to HHS in response to the IFR. Our draft comments urge HHS to increase transparency, strengthen consumer protections, and provide assistance to providers, who are often the key intermediaries between patients and insurance plans. The National Council is seeking input from members on our comments before we submit them to HHS. If you have thoughts or suggestions for improving the draft comments, please contact Stacey Larson at staceyl(at)thenationalcouncil(dot)org by 5:00pm on Sept. 16.
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