New rules make it easier for public to appeal denials of health insurance claims

Posted on July 22, 2010 | Comment (1)
Filed under Department of Health and Human Services, Department of Labor, Department of the Treasury, Health Insurance, Key Developments, Rulemaking, Rules, and Guidance

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Key Developments

Implementation Briefs

On July 22nd, new rules were issued easing patients’ ability to appeal health insurance claim denials. The new regulations guarantee that patients can appeal denials directly to insurers and then to an external review board, if necessary.

Comment (1)

HHS issues request for comment on external review of denials – Health Reform GPS: Navigating the Implementation Process says:

November 16, 2010 at 4:19 pm

[...] has issued a request for comment on external review for health plan denials. This follows the IFR published in July 2010. HealthCare.gov — A website maintained by the Office of Consumer Information and Insurance [...]

HHS, Labor and Treasury extend temporary state external review process standards

March 18, 2013

In a guidance issued Friday, the US Department of Health and Human Services (HHS), US Department of Labor, and US Department of the Treasury extended the interim standards for state external review processes. These standards are meant to make health care claim denials easier for patients to appeal, as set forth in the Affordable Care Act (ACA). Under the new guidance, health insurance issuers will be deemed compliant as long as their external review processes meet the National Association of Insurance Commissioner (NAIC) interim process standards established by Technical Release No. 2011-02. The transitional period expires January 1, 2016, and issuers will then have to meet the standards from the July 2010 regulations issued by the federal government.

Appeals of Claims for Benefits

August 29, 2010

The right to a fair and impartial appeal when a group health plan or health insurer denies a claim would seem to be a basic matter of fairness. Historically, however, this has not been the case. Patient protections vary tremendously depending on the type of health insurance and federal and state legal requirements.