PPACA Update: External Claims Appeals Requirement

Applies to all nongrandfathered plans, whether fully insured or self-funded, and to all sizes of employers.

PPACA requires all nongrandfathered plans to follow detailed processes for claims appeals, including a process for external review that includes 16 consumer protections required under the NAIC model act.  Due to practical difficulties meeting these requirements, interim rules were issued that only required these reviews to meet some of the consumer protections.  The interim rules have now been extended, giving insurers and self-funded plans until Jan. 1, 2016 to meet the full external review requirements.

The notice extending the transition period for the external review process is here:

Technical Release No. 2013-01