The Patient Protection and Affordable Care Act, Public Law 111-148, was enacted on March 23, 2010. Section 2719 of the PHS Act generally requires that group health plans and health insurance issuers have an effective internal claims and appeals process. The statutory language provides further that plans and health insurance issuers in the group market shall provide and internal claims and appeals process that initially incorporates the procedures of 29 CFR 2560.503-1 (the DOL claims procedure regulation) and shall update such procedures in accordance with any standards established by the Secretary of Labor for such plans and issuers.
Uniform Health Carrier External Review Model Act
The purpose of this Act is to provide uniform standards for the establishment and maintenance of external review procedures to assure that covered persons have the opportunity for an independent review of an adverse determination or final adverse determination, as defined in this Act.
Self-insured health plans that do not meet grandfathered rules must now contract with three IRO vendors who will receive case submissions on a rotating basis. These organizations must be accredited by URAC or a similar, nationally recognized accrediting organization. Per the August 23, 2010, DOL’s Technical Release, there will be a safe harbor to ensure that no action will be taken against these plans in the interim of the Federal External Review implementation.
South Florida Utilization Review is URAC accredited and meets all of the requirements mentioned above. To read more on this Act please follow these links.
https://www.dol.gov/ebsa/newsroom/tr10-02.html