External Review

Your rights

Prior to the enactment of the Affordable Care Act (Obamacare), most health plans had a process that let you appeal the insurance company’s decisions. That process was called an internal appeal.

Depending on your State’s laws and your type of coverage, there was no guarantee that the process would be swift and objective. Moreover, if you lost your internal appeal, there was no guarantee that you would be able to ask for an external appeal to an independent reviewer.

♦ That changed when the Affordable Care Act was signed in to law. For the first time, the patient is guaranteed the right to appeal decisions made by their health plan to an outside, independent decision-maker, no matter what State they live in or what type of health coverage they have.

If a patient’s internal appeal is denied, patients in new plans will have the right to appeal all denied claims to an independent reviewer not employed by their health plan.

► But this does not apply to self-insured group health plans which cover most privately insured Americans and which states cannot regulate.

♦ In 2015, CMS made a rule change. It now states that upon receiving a request for external appeal, a group health plan must complete a preliminary review to determine whether the claim is eligible.

If the plan determines the claim is ineligible, it must notify the consumer why and provide the toll-free number at the U.S. Department of Labor.

The regulation does not describe any further recourse for consumers who disagree with the health plan’s determination.

Recent regulations to implement the No Surprises Act added surprise medical bills to the scope of claims eligible for external review, but made no other changes, including to the process under which plans determine eligibility for external review.

♦ Employers with a self-insured plan that is considered grandfathered (existing prior to the Affordable Care Act) do not have to provide an external review process if one did not already exist prior to the ACA taking effect.

However, State laws may require an external review be provided.

♦ According to a study performed by the Centers for Medicare & Medicaid Services it was found that – in States that had external appeals – consumers won their external appeal 54% of the time.

There are 2 steps in the external review process

1. You file an external review: You must file a written request for an external review within 60 days of the date your insurer sent you a final decision.

Some plans may allow you more than 60 days to file your request. The notice sent to you by your health insurance issuer or health plan should tell you the time frame in which you must make your request.

2. External reviewer issues a final decision: An external review either upholds your insurer’s decision or decides in your favor.

Your insurer is required by law to accept the external reviewer’s decision.

Types of denials that can go to external review

The external review can be for adverse benefit determinations that involve:

• Medical necessity

• Appropriateness

• Health care setting

• Level of care

• Effectiveness of a covered benefit

• Whether a treatment is experimental or investigational

• Any other matter that involves medical judgment

If your health insurance is retroactively cancelled, you may also request an external review.

What are my rights in an external review?

Insurance companies in all states must participate in an external review process that meets the consumer protection standards of the health care law.

State: Your state may have an external review process that meets or goes beyond these standards. If so, insurance companies in your state will follow your state’s external review processes. You’ll get all the protections outlined in that process.

Federal: If your state doesn’t have an external review process that meets the minimum consumer protection standards, the federal government’s Department of Health and Human Services (HHS) will oversee an external review process for health insurance companies in your state.

Depending on your plan and where you live

The following may apply to you:

• Insurance companies may choose to participate in an HHS-administered process or contract with independent review organizations in states where the federal government oversees the process.

• If you’re in an employer-sponsored health plan, you may not be eligible to participate in a state-run external review process.

♦ Grandfathered health plans are exempt.

• If your plan doesn’t participate in a state or HHS-administered external review process, your health plan must contract with an independent review organization.

How do I learn more about my state’s external review?

• Look at the information on your Explanation of Benefits (EOB) or on the final denial of the internal appeal by your health plan. It’ll give you the contact information for the organization that will handle your external review.

• See this state list maintained by the HHS’s Center for Consumer Information & Insurance Oversight.

How long does an external review take?

Standard external reviews are decided as soon as possible - no later than 60 days after the request was received.

If your health insurance company participates in the HHS-administered external review process then the review will be handled by Maximus Federal Services, Inc. The HHS has contracted with Maximus to provide independent reviews of claims denied by insurance companies.

How do I request an external appeal?

• Call toll free: 1-888-866-6205 to request an external review request form. Then fax an external review request to: 1-888-866-6190.

• Mail an external review request form to: MAXIMUS Federal Services 3750 Monroe Avenue, Suite 705 Pittsford, NY 14534

• Visit the HHS-Administered Federal External Review Process website. In the future, you’ll be able to file a request using a secure website.

Can someone file an external review for me?

You may appoint a representative (like your doctor or another medical professional) who knows about your medical condition to file an external review on your behalf.

An Appointment of Representative form is also available at the HHS-Administered website.

How much does an external review cost?

If your health insurance company is using the HHS-administered external review process, there’s no charge.

If your issuer has contracted with an independent review organization, or is using a state external review process, you may be charged. If so, the charge can’t be more than $25 per external review.