Health Care Reform – Guidance Issued on Internal Claims and Appeals, and External Review Processes


On July 23, 2010, the Department of Treasury, in conjunction with the Department of Labor and the Department of Health & Human Services ("HHS"), issued interim final rules for non grandfathered plans implementing the internal claims and appeals and external review processes for group health plans and health insurance issuers under the Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010 (collectively, the "Health Care Reform Act"). The following discusses the requirements of these interim rules with regard to employer-sponsored group health plans.

Requirements for Internal Claims and Appeals Processes.

The interim rules provide that group health plans and health insurance issuers offering group or individual health insurance coverage, but not offering grandfathered plans, must comply with the internal claims and appeals requirements as set forth in the regulations under ERISA. In addition, the rules impose the following requirements...

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