Amended by section 10101 of the Manager’s Amendment. Requires plans offering individual or group coverage to implement an effective process for appeals of coverage determinations and claims meeting specified parameters such as having an internal claims appeal process and notifying enrollees of available internal/external appeals processes.
Group health plans and health insurance issuers offering group or individual coverage must comply with the applicable binding State external review process that, at minimum, includes the consumer protections set forth in the NAIC Uniform External Review Model Act.
If the State has not established an external review process that meets this section’s requirements or the plan is self-insured and not subject to it, the plan must implement an effective external review process that meets HHS standards. Allows HHS to deem a plan’s existing external review process.