The Affordable Care Act (ACA) ensures that consumers have the right to appeal certain health insurance plan decisions. This means they are able to ask that the plan reconsider its decision to deny payment for a service or treatment. ACA rules spell out how plans must handle an appeal (usually called an “internal appeal”). These rules apply to non-grandfathered plans, which include health insurance policies that were first sold or significantly modified in certain ways after March 23, 2010. For more information on when plans are considered grandfathered, see https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/. If the plan still denies payment after considering the internal appeal, the law permits a consumer to take another step. Consumers may choose to have an independent review organization (an outside independent decision-maker) decide whether to uphold or overturn the plan’s decision. This additional check is often referred to as an “external review.”
Rules issued by the U.S. Departments of Health and Human Services (HHS), Treasury, and Labor (DOL) provide for three different ways to process external reviews. In some states, consumers will use their state’s external review process. This method is for states determined by the federal government to have an external review process that meets the federal consumer protection standards. To see whether a state’s external review process meets our standards, go to http://www.cms.gov/cciio/resources/files/external_appeals.html.
If the state’s process does not meet the federal consumer protection standards, issuers must offer to consumers one of two federally-sanctioned processes:
The HHS-Administered Federal External Review Process applies to “adverse benefit determinations,” including those that involve medical judgment (including, but not limited to, those based on the plan’s or issuer’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit; or its determination that a treatment is experimental or investigational) and rescissions of coverage (whether or not the rescission has any effect on any particular benefit at that time).
The HHS-Administered Federal External Review Process is available at no cost to the health insurance plan, the consumer, or a consumer’s authorized representative. Issuers that elect to use the HHS-Administered Federal External Review Process and consumers whose plan is participating in the HHS-Administered Federal External Review Process, will work with a designated federal contractor which, in consultation with, and on behalf of HHS, performs the administrative functions of the external review. This contractor is MAXIMUS Federal Services, Inc. (MAXIMUS). MAXIMUS, on behalf of HHS, also provides technical assistance to consumers related to external review requests. For more information, please visit the external appeals website at: externalappeal.cms.gov/ - Opens in a new window
If a health insurance plan denies a benefit, refuses to pay for a service that has already been received, or rescinds coverage, this is called an adverse benefit determination. If a health insurance plan upholds its earlier adverse benefit determination, this is called a final internal adverse benefit determination.
Consumers may ask for an external review of a final internal adverse benefit determination. In some instances, consumers may ask for an external review when the initial denial (adverse benefit determination) is made.
A consumer or their authorized representative (called the “claimant”) may file a written request for an external review.
A consumer may file a request with MAXIMUS within four months after the date of receipt of a notice of an adverse benefit determination or final internal adverse benefit determination. Consumers may send requests by mail, facsimile, email, or through a secure, online portal. While we will still continue to accept external review requests submitted by email, mail, or facsimile, we strongly encourage all issuers and claimants who are able to do so to use the online portal to submit their review requests.
After MAXIMUS receives an external review request, MAXIMUS contacts the health insurance issuer. The issuer must provide all documents related to the adverse benefit determination to MAXIMUS within five business days.
Claimants may also submit any additional information they want MAXIMUS to consider during the external review.
MAXIMUS will review all of the information and documents that are submitted with your request, as long as they are submitted on or before the four-month deadline.
For a standard external review, the MAXIMUS examiner must provide written notice of the final external review decision as expeditiously as possible and no later than 45 days after the examiner receives the request for the external review. Claimants will receive external review determinations in writing.
For urgent care situations, claimants may file an expedited external review for either an adverse benefit determination or a final internal adverse benefit determination if:
For an expedited external review, the MAXIMUS examiner must provide notice of the final external review decision as expeditiously as the medical circumstances require and within 72 hours once the examiner receives the request for the external review. MAXIMUS must deliver the notice of final external review decision to the claimant and the health insurance issuer as soon as possible. This notice can be initially provided orally but must be followed up in writing within 48 hours.
Decisions made by MAXIMUS are final, and there is no further review available under the HHS-Administered Federal External Review Process after a claimant receives a decision. This decision is binding on both the claimant and the health plan or issuer, except when there are other remedies available for the claimant under federal or state law, such as filing a lawsuit. If you are a consumer, health insurance issuer, or health care provider interested in learning more about the HHS-Administered Federal External Review Process, please visit the CMS External Appeals web page at: http://www.cms.gov/cciio/Programs-and-Initiatives/Consumer-Support-and-Information/External-Appeals.html or call toll-free at 1-888-866-6205.
Health insurance issuers may also wish to contact MAXIMUS directly at: email@example.com.