The Affordable Care Act (ACA) ensures that consumers have the right to appeal 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. New rules spell out how plans must handle an appeal (usually called an “internal appeal”). These rules apply to health insurance policies that were first sold or significantly modified after March 23, 2010. These plans are calls non-grandfathered plans. If the plan still denies payment after considering the internal appeal, the law permits a consumer 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 a process that meets the federal standards for consumer protections. Go to http://www.cms.gov/cciio/resources/files/external_appeals.html to see whether a state’s external review process meets our standards.
If the state’s process does not meet the federal consumer protection standards, issuers must use a federally-administered external review process and may choose one of the following external review processes to offer to consumers:
■ The accredited Independent Review Organization (IRO) contracting process or
■ The HHS-Administered Federal External Review Processes.
The federally-administered external review processes apply to denials (called “adverse benefit determinations”) 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 the designated federal contractor which performs all functions of the external review. This contractor is MAXIMUS Federal Services, Inc. (MAXIMUS). MAXIMUS is also providing technical assistance to consumers related to external review requests. For more information, please visit the MAXIMUS website at: www.externalappeal.com - Opens in a new window .
If a health insurance plan denies a benefit or refuses to pay for a service that has already been received, this is called an adverse benefit determination. If a health insurance plan upholds its earlier decision to deny a benefit or payment for a service, 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. Consumer may send requests by mail, facsimile, or email. In the near future, they will be able to file a request through a secure, online portal.
After MAXIMUS receives an external review request, MAXIMUS contacts the health insurance issuer. The issuer must provide all documents and information related to the denial to the 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 on time.
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. This notice can be initially provided orally but must be followed up in writing within 48 hours.
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.