• Claims and Appeals Procedures: New Internal and External Review Requirements
  • August 30, 2010 | Authors: Patricia Eschbach-Hall; Marlene P. Frank; Sarah Heck Griffin; Evan Miller
  • Law Firms: Jones Day - Cleveland Office ; Jones Day - Columbus Office ; Jones Day - Los Angeles Office ; Jones Day - Cleveland Office ; Jones Day - Washington Office
  • The Patient Protection and Affordable Care Act, as amended (“PPACA”), requires group health plans and health insurance issuers to provide both an internal claims and appeals process and an external review process. Because this new requirement (the “Appeal and Review Mandate”) applies to both group and individual insured coverage as well as to self-insured plans, the same process for administratively contesting a denied claim for health benefits will be available to all covered individuals, regardless of state of residence or source of coverage. The Appeal and Review Mandate is effective for plan years beginning on or after September 23, 2010 (January 1, 2011, for calendar-year plans), and does not apply to grandfathered plans.