Appeal and grievance procedures (internal claims and appeals; external review)

Requirement overview

• Beginning 9/23/2010, health plans must have an internal appeals process that:
• Allows members to appeal when it denies a claim for a covered service or rescinds coverage;
• Gives members detailed information about why the claim or coverage was denied;
• Requires the plan to notify members about their right to appeal and tell them how to begin the appeals process;
• Ensures a full and fair review of the denial; and
• Provides members with an expedited appeals process in urgent cases.
• Members can appeal the outcome of the plan's internal review through an external review process if they're dissatisfied with the result. 
• The external review is currently offered by Michigan's Office of Financial and Insurance Regulation for fully funded employers.
• Plans must tell members, in a culturally and linguistically appropriate manner, about available internal and external appeals processes, any applicable office of health insurance consumer assistance or ombudsman established to help members with the appeals process.
• A member can review their file and present evidence and testimony as part of the appeals process.
• Members must receive continued coverage pending the outcome of the appeals process.

On 9/20/2010, HHS published interim procedures establishing an enforcement grace period, giving plans until 7/1/2011 to comply.  

What Priority Health is doing

• Information about our appeals process appears in member materials and on this website. See appeals information.
• This process is being updated to comply with the new appeals requirements.
• The appeals process will be the same for all plans (grandfathered and non-grandfathered).

What you need to do

• Must implement an external review process.
• Should look for details about the external review process coming soon.
• The State of Michigan has not yet decided if it will provide external review for self-funded employers. If the State of Michigan doesn't, you'll be subject to the guidelines of the NAIC Uniform Model Act external review process.
• We are contracting with at least 3 independent review organizations (IROs). We will help you prepare for the external review process.