HHS Update to Technical Guidance 01-2018: Standards for Self-Insured Non-Federal Governmental Health Plans and Health Insurance Issuers Offering Group and Individual Health Coverage Using the HHS- Administered Federal External Review Process (July 12, 2019)
HHS has updated its technical guidance setting forth requirements for group health plans and insurers using the HHS-administered federal external review process. As background, for specified types of adverse benefit determinations, group health plans must make available an external review process meeting certain standards, either pursuant to a state process (generally applicable to insurers and self-insured plans not subject to ERISA) or a federal process (for self-insured ERISA plans). Insured plans not subject to an applicable state external review process and self-insured non-federal governmental plans may elect to use a federal external review process pursuant to applicable regulations (see our Checkpoint article) or the HHS-administered federal external review process outlined in this guidance. This update replaces previous versions (see, for example, our Checkpoint article).
The updated guidance announces that MAXIMUS, the federal contractor that administers this process on behalf of HHS, now offers an online portal for requesting an external review. It also advises that notices of adverse benefit determination and final internal adverse benefit determination will need to be updated to note this new feature. The notices must provide the web address for the portal, explain how to submit the request online, include information about submitting external review requests by mail or fax, and state that expedited review may be requested via the online portal or by phone or email. The guidance provides the relevant web address, street address, phone and fax numbers, and email address. Plans and insurers must electronically submit samples of their updated notices to HHS. In other respects, the external review procedures described in this guidance remain generally unchanged from prior versions.
EBIA Comment: Plans and insurers using the HHS-administered federal external review process should act quickly to update their notices and submit them to HHS, as it appears that the online portal is already in use. For more information, see EBIA’s Health Care Reform manual at Section XV (“Appeals Process and External Review Requirements”). See also EBIA’s ERISA Compliance manual at Section XXXIV.M (“External Review Requirements”) and EBIA’s Self-Insured Health Plans manual at Section XXVI.H (“External Review Requirements for Self-Insured Health Plans”).
Contributing Editors: EBIA Staff.