Guidance on Claims, Appeals and External Review Under ACA

Guidance on Claims, Appeals and External Review Under ACA – The Affordable Care Act’s requirement that health plans and insurers must follow new and revised procedures for claims, internal appeals and external review.  These new requirements are effective for plan years beginning on or after September 23, 2010, although there is some transition relief.  Grandfathered plans that were in effect on March 23, 2010 need not comply as long as they maintain grandfather status.   Interim regulations describe changes to existing DOL claims procedures regulations and provide the requirements of a State external review (based on the Model Uniform External Review Act).  Model notices of initial determination, final determination and external review have been issued.  A DOL technical release gives temporary guidance on the Federal external review process, which would apply to self-insured plans.   For further information see memo at  (Charles C. Shulman

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