The Departments of Treasury, Labor and Health and Human Services have issued guidance addressing the internal claims and appeals and external review processes. The requirements set forth in these interim final regulations apply only to non-grandfathered group health plans and are effective the first plan year beginning after Sept. 23, 2010 for calendar year plans starting Jan. 1, 2011. PPACA requires all non-grandfathered group health plans to implement an external review process in addition to the internal claims appeal process already mandated under ERISA.

The interim final rule provides guidance on the new, mandatory external review process required under PPACA and makes changes to the existing standards for internal claims and appeals.

Internal Claims and Appeals Processes

Under PPACA, group plans and insurers offering group coverage must implement internal claims and appeals processes that comply with the claims and appeals procedures requirements under Section 503 of the Employee Retirement Income Security Act (ERISA), if they are not already subject to those requirements (e.g., church and governmental plans). In addition, the interim final rule creates six new requirements for group health plans and insurers, including the definition of a denial to include a rescission of coverage and that urgent care claims must be decided and the claimant must be notified within 24 hours after the plan or insurer receives the claim.

External Review Process

For the external review standards, the guidance provides a basis for determining when plans and issuers must comply with an applicable State external review process and when they must comply with the Federal external review process.

Click here to view the interim final rules.