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Appeals

Summary

The health reform law requires non-grandfathered group health plans and health insurance companies to provide consumers with an effective internal claims, appeals and external review process for members to challenge an adverse benefit determination (ABD).

This requirement includes notice to members of available appeals processes, along with an opportunity to review their file and present evidence.

Upon Further Review – Appeals Under the Affordable Care Act

If your health plan denies payment for a treatment that you believe should be covered, you have the right to challenge that decision and appeal it.

Among the key components of the appeals provision is a broader definition of "adverse benefit determination" to include a rescission of coverage, generally defined as a cancellation or discontinuance of coverage that has a retroactive effect.

New conflict of interest criteria are in place to guarantee the independence of the decision-maker.

Also included is the requirement to provide a decision regarding urgent care claims within 72 hours of receipt of a claim, consistent with the medical issues involved. ABD notices must provide information sufficient to identify the claim involved, inform recipients of the availability of consumer assistance (and/or ombudsman programs) and offer to translate notices to a language other than English if certain criteria set forth in the law are met.

In addition, all ABDs will include a statement that diagnosis and treatment codes are available upon request (if diagnosis and treatment codes do not already appear on the ABD).

Non-grandfathered fully insured and self-funded plans must comply with either a state external review process or a federal external review process, as applicable. Where a state external process is not applicable, UnitedHealthcare has contracted with four accredited vendors to act as Independent Review Organizations (IRO) for its external review program (federal external review process). Federal external review currently applies only to claims that involve medical judgment or a rescission of coverage.

The IROs were selected because of their national accreditation for quality reviews, a wide national spectrum of specialist physician review networks and their ability to meet strict compliance requirements including turnaround times and provider specialty match.

UnitedHealthcare's appeals processes meet the health reform law requirements. UnitedHealthcare has revised its template summary plan description (SPD) language to reflect requirements specific to the appeals and external review processes.

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