IRS Wants Input on Streamlining Health Claim Appeals Process
Published Date: 3/4/2026
Notice
Summary
The IRS wants your thoughts on how it collects info about Affordable Care Act claims and appeals. This affects health insurers and people dealing with claim disputes, aiming to make the process clearer and less of a hassle. Comments are open until May 4, 2026, so jump in and help shape smoother health claim rules without extra costs or headaches!
Analyzed Economic Effects
3 provisions identified: 3 benefits, 0 costs, 0 mixed.
External Review Required for Grandfathered Plans
If you have a grandfathered health plan, the No Surprises Act means your plan must provide external review for adverse benefit determinations that involve surprise-billing protections. That requirement applies to grandfathered plans because the law’s definitions include both grandfathered and non-grandfathered plans.
Free Access to Evidence in Appeals
If you are a claimant in a claim dispute, your grandfathered or non-grandfathered plan must give you, free of charge, any new or additional evidence the plan considered, relied upon, or generated in connection with your claim. Plans must also follow either a State external review process or the Federal external review process for external reviews.
Federal External Review Procedural Rules
Under the Federal external review process, plans must perform a preliminary review of external appeal requests. Independent Review Organizations (IROs) must notify claimants about eligibility and acceptance, receive documentation from plans, forward claimant submissions to plans, notify parties of final results, and keep records for six years; plans must notify claimants and IROs if they reverse a decision.
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