42 U.S.C. § 300gg–19 — Appeals process

submitted 82 years ago by Pub. L. 111-148 to r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE · 480 words · no verdicts yet

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Health plans must let members appeal denied claims, inside the plan first. Members can review their file and keep coverage while the appeal is pending. After that internal appeal, an independent outside reviewer can make the final call.

(a) Internal claims appeals. (1) In general. A group health plan and an issuer must run an effective appeals process for coverage and claims decisions. At minimum, the plan or issuer must: (A) have an internal claims appeal process in place; (B) tell enrollees, in a culturally and linguistically appropriate way, about the internal and external appeals processes available, and about any consumer assistance office or ombudsman set up under section 300gg–93 of this title that can help them appeal; and (C) let an enrollee review their own file, present evidence and testimony during the appeal, and keep their coverage while the appeal is pending. (2) Established processes. (A) For a group health plan or an issuer offering group coverage, the internal process must start out using the claims and appeals rules the Department of Labor published on November 21, 2000 (29 CFR § 2560.503-1), and must be updated to match any newer standards the Secretary of Labor sets. (B) For an issuer offering individual coverage — or any other issuer not covered by (A) — the internal process must start out using the claims and appeals rules that applied under the law as of March 23, 2010, and must be updated to match any newer standards the Secretary of Health and Human Services sets. (b) External review. A group health plan and an issuer must either: (1) follow their state's external review process, as long as that process gives at least the consumer protections in the NAIC's Uniform External Review Model Act and is binding on the plan; or (2) run their own effective external review process, meeting minimum standards the Secretary sets and similar to the state process in (1), if either (A) the state hasn't set up a process good enough to satisfy (1), or (B) the plan is self-insured and not subject to state insurance regulation. (c) Secretary authority. The Secretary may decide that an external review process already running as of March 23, 2010 counts as meeting subsection (b), if the Secretary judges that appropriate.

the actual law source: uscode.house.gov ↗public domain

(a) Internal claims appeals

(1) In general

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum—

(A)

have in effect an internal claims appeal process;

(B)

provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 300gg–93 of this title to assist such enrollees with the appeals processes; and

(C)

allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process.

(2) Established processes

To comply with paragraph (1)—

(A)

a group health plan and a health insurance issuer offering group health coverage shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503–1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70256), and shall update such process in accordance with any standards established by the Secretary of Labor for such plans and issuers; and

(B)

a health insurance issuer offering individual health coverage, and any other issuer not subject to subparagraph (A), shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures set forth under applicable law (as in existence on March 23, 2010), and shall update such process in accordance with any standards established by the Secretary of Health and Human Services for such issuers.

(b) External review

A group health plan and a health insurance issuer offering group or individual health insurance coverage—

(1)

shall comply with the applicable State external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans; or

(2)

shall implement an effective external review process that meets minimum standards established by the Secretary through guidance and that is similar to the process described under paragraph (1)—

(A)

if the applicable State has not established an external review process that meets the requirements of paragraph (1); or

(B)

if the plan is a self-insured plan that is not subject to State insurance regulation (including a State law that establishes an external review process described in paragraph (1)).

The Secretary may deem the external review process of a group health plan or health insurance issuer, in operation as of March 23, 2010, to be in compliance with the applicable process established under subsection (b), as determined appropriate by the Secretary.

Source credit: (July 1, 1944, ch. 373, title XXVII, § 2719, as added and amended Pub. L. 111–148, title I, § 1001(5), title X, § 10101(g), Mar. 23, 2010, 124 Stat. 137, 887.)

history & why it existsrecord from the source credit

1944Enacted · Pub. L. 111-148 · 124 Stat. 137, 887

A history note hasn’t been published yet. The record shows enactment by Pub. L. 111-148 on 1944-07-01.

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