Human Resources
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Agencies Release Amended Procedures for Internal Claims and Appeals and External Review

The Departments of Health and Human Services (HHS), Labor (DOL), and Treasury on June 22, 2011 released an amendment to the interim final rules relating to internal claims and appeals and external review processes that were issued on July 23, 2010. The amendment to the interim final regulations is intended to respond to previous comments provided to the agencies, as well as to help group health plans and health insurance issuers comply with the regulations. Also on June 22, 2011, the DOL’s Employee Benefits Security Administration (EBSA) issued Technical Release 2011-02 providing additional guidance on external review for group health plans and health insurance issuers as well as revised model notices.

These new internal claims and appeals and external review processes were implemented under the Patient Protection and Affordable Care Act (Affordable Care Act) (P.L. 111-148). Under the Affordable Care Act, group health plans and health insurance issuers that are not grandfathered health plans, or that lose their grandfathered health plan status, are required to comply with these new rules, including an external review process. This report focuses solely on the changes to the processes that apply to coverage provided by group health plans or group health insurance coverage.

Aon Hewitt's report, which provides more details on the amendment and Technical Release 2011-02, is available below.

Agencies Release Amended Procedures for Internal Claims and Appeals and External Review