White House Unveils Consumer Rules to Appeal Health Plan Decisions

Janice Simmons, for HealthLeaders Media , July 23, 2010

If a patient’s internal appeal is denied, patients in new plans will have the right to appeal all denied claims to an independent reviewer not employed by their health plan. However,   while 44 states provide some form of external appeal, the laws governing these processes had varied greatly.

States are being encouraged to make changes in their external appeals laws and to adopt these standards before July 1, 2011. The new standards call for:

  • External review of plan decisions to deny coverage for care based on medical necessity, appropriateness, healthcare setting, level of care, or effectiveness of a covered benefit.
  • Clear information for consumers about their right to both internal and external appeals.
  • Review by an independent body assigned by the state. The state must also ensure the reviewers meet certain standards, keep written records, and are not affected by conflicts of interest.
  • Emergency processes for urgent claims, and a process for experimental or investigational treatment.

Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.

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