The feds just issued new regs that’ll make it easier for your employers to appeal health insurance claims denials.
New interim final regs guarantee individuals the right to appeal denials directly to their insurers — and then, if necessary, to external review boards.
And for the first time, the external review requirement will apply to self-insured companies.
Federal review system
All but five states — Alabama, Mississippi, Nebraska, North Dakota and South Dakota — already provide individuals with the right to external appeals, but with varying rules.
Those five outliers are being asked to establish an external review system by July 2011. If they don’t, a federal review system will be set up that residents in those states can use.
New requirements
The new regs take effect for plan years starting on or after Sept. 23 — but won’t apply to those states with existing external review laws until next July to give those states time to adjust to the new standards.
A few of the requirements set forth by the new regs:
- Consumers have the right to appeal decisions made by their health plan through the plan’s internal process.
- Health plans must give participants detailed information about the grounds for the denial of claims or coverage.
- Health plans are required to notify participants about their right to appeal adverse benefits determinations and instruct them on how to begin the appeals process.
- In urgent cases, plan participants must be allowed an expedited appeals process.
- The definition of an adverse benefit determination now includes rescission of coverage.
The new regs won’t apply to grandfathered plans.
For more info on the interim final regs click here.
