On July 12, 2019, the HHS issued an update to Technical Guidance-01-2018 for self-insured, non-federal governmental health plans (and insurance carriers in the group and individual markets) that rely upon the HHS-administered federal external review process. As background, non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual coverage must comply with the applicable external review process in their state if that process meets the standard established by the National Association of Insurance Commissioners (NAIC). If the state external review process does not meet this standard, or if the plan or issuer is not subject to state insurance regulation, then those group health plans and health insurance issuers must still implement an effective external review process meeting those same standards. The Code of Federal Regulations establishes the federal external review process for this purpose.

The guidance notes that MAXIMUS, a federal contractor, has started accepting online requests for external review through their online portal. As a result, there are now three options for employees (policyholders) and beneficiaries to request an external review (the other options being via mail or fax). Plans that use the HHS-administered external review process must now update the applicable notices to properly describe these available options.

This technical release also replaces technical guidance issued September 11, 2018 by providing a revised website address where a claimant can make an online request for external review.

The federal external review process requires an adverse benefit determination or a final internal adverse benefit determination to contain a notice to the claimant that the claimant can request an external review of the adverse benefit determination or final internal adverse benefit determination. A claimant can now submit such a request online to externalappeal.cms.gov under the “Request a Review Online” heading, in writing by faxing their request to 1.888.866.6190, or by sending it by mail to: MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534.

Self-insured employers that rely upon the HHS-administered federal external review process should update the notice to properly inform claimants of their three options for requesting an external review (via email, mail, fax, or through the online portal).

Update to Technical Guidance-01-2018 »

Source: NFP BenefitsPartners