Federal Law

Title 42- Chapter 6A-Requirements Relating to Health Insurance Coverage-Individual and Group Market Reforms

12/08/2020 42 USC § 300gg-19

Appeals process

ERISA-Med. Nec. Appeals-Deadlines, ERISA-Med. Nec. Decisions-Deadlines

This law is part of the Public Health Service Act, that was amended by the Patient Protection and Affordable Care Act of 2010.  The bold sections indicate where this law incorporates ERISA regulations concerning medical necessity decisions and appeals.

(a) Internal claims appeals.

(1) In general. A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum–

(A) have in effect an internal claims appeal process;

(B) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 [42 USCS § 300gg-93] to assist such enrollees with the appeals processes; and

(C) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process.

(2) Established processes. To comply with paragraph (1)–

Incorporation of ERISA regulation’s medical necessity decision and appeal requirements.

(A) a group health plan and a health insurance issuer offering group health coverage shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70256), and shall update such process in accordance with any standards established by the Secretary of Labor for such plans and issuers; and

(B) a health insurance issuer offering individual health coverage, and any other issuer not subject to subparagraph (A), shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures set forth under applicable law (as in existence on the date of enactment of this section), and shall update such process in accordance with any standards established by the Secretary of Health and Human Services for such issuers.

(b) External review. A group health plan and a health insurance issuer offering group or individual health insurance coverage–

(1) shall comply with the applicable State external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans; or

(2) shall implement an effective external review process that meets minimum standards established by the Secretary through guidance and that is similar to the process described under paragraph (1)–

(A) if the applicable State has not established an external review process that meets the requirements of paragraph (1); or

(B) if the plan is a self-insured plan that is not subject to State insurance regulation (including a State law that establishes an external review process described in paragraph (1)).

(c) Secretary authority. The Secretary may deem the external review process of a group health plan or health insurance issuer, in operation as of the date of enactment of this section [enacted March 23, 2010], to be in compliance with the applicable process established under subsection (b), as determined appropriate by the Secretary.

See https://www.govinfo.gov/app/details/USCODE-2011-title42/USCODE-2011-title42-chap6A-subchapXXV-partA-subpartii-sec300gg-19