New ERISA Appeal Letters Coming in August
Patient Protection and Affordable Care Act will extend ERISA Appeals Protections.
The Patient Protection and Affordable
Care Act (PPACA) is extending new appeal protections which
will make it easier for providers to assist patients with
denied medical claims.
The law provides consumers with a way to appeal coverage
determinations or claims to their insurance company and
establishes an external review process. These changes are
effective for health plans beginning on or after September
The PPACA mandates stricter appeal
review and disclosure guidelines which are expected to
affect claim denials related to medical necessity,
experimental/investigational, emergency care, maximum
benefits and usual, reasonable and customary calculations.
The law seeks to simplify the appeal
process by providing federal requirements applicable to all
plans. Carrier will be required to provide an internal
appeal review process in compliance with state appeal review
or ERISA regulations and an external review process in
compliance with state external review law or the Uniform
External Review Model Act promulgated by the National
Association of Insurance Commissioners (NAIC).
The AppealLettersOnline.com August
newsletter will feature instructions on using PPACA
protections in appeals and will provide a number of new
letters citing the extended protections. Be sure to
signup as a member so that you have access to this