A member has the right to take the appeal to an independent third party for review. This is called external review. External review means that the insurance company no longer gets the final say over whether to pay a claim.
There are 2 steps in the external review process:
1. The member files for an external review: They must file a written request for an external review within four months of the date the insurer sent the final decision. The notice sent to the member by the health insurance issuer or health plan should tell them the timeframe in which they must make the member's request.
2. External reviewer issues a final decision: An external review either upholds the insurer's decision or decides in the members favor. The Independent Review Organization has the final say. The insurer is required by law to accept the external reviewer's decision.
In some states, consumers will use their state's external review process. This method is for states determined by the federal government to have a process that meets the federal standards for consumer protections.
If the state's process does not meet the federal consumer protection standards, issuers must use a federally-administered external review process and may choose one of the following external review processes to offer to consumers:
- The accredited Independent Review Organization (IRO) contracting process or
- The Health and Human Services (HHS)-Administered Federal External Review Processes.
The federally-administered external review processes apply to denials (called "adverse benefit determinations") that involve medical judgment (including, but not limited to, those based on the plan's or issuer's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit; or its determination that a treatment is experimental or investigational) and rescissions of coverage (whether or not the rescission has any effect on any particular benefit at that time).
The HHS-Administered Federal External Review Process is available at no cost to the health insurance plan, the consumer, or a consumer's authorized representative. Issuers that elect to use the HHS-Administered Federal External Review Process and consumers, whose plan is participating in the HHS-Administered Federal External Review Process, will work with the designated federal contractor which performs all functions of the external review. This contractor is MAXIMUS Federal Services, Inc. (MAXIMUS). MAXIMUS is also providing technical assistance to consumers related to external review requests.
The ultimate step in a claims appeal process would be a lawsuit. It is very important the plan administer all claims, denials and appeals appropriately because if an appeal should end up in a courtroom; the whole process will be scrutinized.
This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.