The Patient Protection and Affordable Care Act (PPACA) was enacted on March 23, 2010. The Department of the Treasury, Department of Labor and the Department of Health and Human Services issued interim final regulations implementing the requirements regarding internal claims and appeals and external review processes for group health plans and health insurance coverage in the group and individual markets.
In compliance with the Affordable Care Act and modeled after the Uniform Health Carrier External Review Model Act (NAIC Uniform Model Act), covered persons must have the opportunity for an independent review of adverse determinations or final adverse determinations based on medical judgment or a determination that a recommended or requested health care service or treatment is experimental or investigational or for rescission of coverage. Your plan type and the state of your contract or residence will determine whether your coverage denial is subject to a state or federal standard regulations.
All non-grandfathered plans (self-funded, insured, group & individual) are subject to some form of external review process. Your plan documents will provide a description of the applicable external review process. You will be provided with the applicable external review rights along with a description of how to pursue an external review in the adverse or final adverse determination letter as you exhaust the internal appeal process.
States that have an external review process that meets certain minimum consumer protections set forth under federal requirements will be allowed to apply their state ERO process. Health insurers must comply with the state external review process in those states. If your plan is subject to a state mandated process a description of that process will be provided in your plan documents.
For individual plans and fully insured group health plans in states that do not have external review legislation or where a state does not meet the minimum consumer protections under the federal law, Aetna will administer an ERO process that complies with the federal requirements.