Ama Policy

External Grievance Review Procedures H-320.952

U.R. Criteria

Our AMA establishes an External Grievance procedure for all health plans including those under the Affordable Care Act (ACA) with the following basic components:

(1) It should apply to all health carriers and Accountable Care Organizations;

(2) Grievances involving adverse determinations may be submitted by the policyholder, their representative, or their attending physician;

(3) Issues eligible for external grievance review should include, at a minimum, denials for (a) medical necessity determinations; and (b) determinations by carrier that such care was not covered because it was experimental or investigational;

(4) Internal grievance procedures should generally be exhausted before requesting external review;

(5) An expedited review mechanism should be created for urgent medical conditions;

(6) Independent reviewers practicing in the same state should be used whenever possible;

(7) Patient cost sharing requirements should not preclude the ability of a policyholder to access such external review;

(8) The overall results of external review should be available for public scrutiny with procedures established to safeguard the confidentiality of individual medical information;

(9) External grievance reviewers shall obtain input from physicians involved in the area of practice being reviewed. If the review involves specialty or sub-specialty issues the input shall, whenever possible, be obtained from specialists or sub-specialists in that area of medicine.

Policy Timeline

Res. 701, I-98 Reaffirmation I-99 Reaffirmation A-00 Reaffirmed: CMS Rep. 6, A-10 Reaffirmed: Res. 709, A-12 Modified: Res. 712, A-13 Reaffirmed in lieu of: Res. 242, A-17 Reaffirmation: I-17