42 U.S.C. § 300gg–19: Appeals process

Summary

Health plans and health insurance companies must have a clear appeals process for denied coverage or claims. They must offer an internal appeal system, tell people in a way they can understand (including language help) about internal and external appeals and any consumer help programs, let people see their file and give evidence or testimony, and keep coverage going while the appeal is decided. Group plans and group insurers must follow the claims rules found in the federal regulation published on November 21, 2000 (29 C.F.R. 2560.503–1) and update them if the Secretary of Labor sets new standards. Individual insurers and others must follow the rules in effect on March 23, 2010 and update them under standards the Secretary of Health and Human Services issues. Plans must use a state external review process that includes the NAIC Uniform External Review Model Act protections, or they must run a federal-style external review if the state has no acceptable process or the plan is self‑insured. The Secretary can accept an external review process already in use on March 23, 2010 as meeting these rules.

Title 42, §300gg–19

The Public Health and Welfare, Source: USLM XML via OLRC

(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 300gg–93 of this title 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)—

(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 March 23, 2010), 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 March 23, 2010, to be in compliance with the applicable process established under subsection (b), as determined appropriate by the Secretary.

Notes & Related Subsidiaries

Editorial Notes

Amendments

2010—Pub. L. 111–148, § 10101(g), amended section generally. Prior to amendment, section related to implementation of appeals process by group health plans and health insurance issuers.

Statutory Notes and Related Subsidiaries

Effective Date

Section effective for plan years beginning on or after the date that is 6 months after Mar. 23, 2010, see section 1004 of Pub. L. 111–148, set out as a note under section 300gg–11 of this title. Consumer Protections Through Application of Health Plan External Review in Cases of Certain Surprise Medical Bills Pub. L. 116–260, div. BB, title I, § 110, Dec. 27, 2020, 134 Stat. 2861, provided that: “(a) In General.—In applying the provisions of section 2719(b) of the Public Health Service Act (42 U.S.C. 300gg–19(b)) to group health plans and health insurance issuers offering group or individual health insurance coverage, the Secretary of Health and Human Services, Secretary of Labor, and Secretary of the Treasury, shall require, beginning not later than January 1, 2022, the external review process described in paragraph (1) of such section to apply with respect to any adverse determination by such a plan or issuer under section 2799A–1 or 2799A–2 [probably means section 2799A–1 or 2799A–2 of the Public Health Service Act, 42 U.S.C. 300gg–111, 300gg–112], section 716 or 717 of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1185e, 1185f], or section 9816 or 9817 of the Internal Revenue Code of 1986 [26 U.S.C. 9816, 9817], including with respect to whether an item or service that is the subject to such a determination is an item or service to which such respective section applies. “(b) Definitions.—The terms ‘group health plan’; ‘health insurance issuer’; ‘group health insurance coverage’, and ‘individual health insurance coverage’ have the meanings given such terms in section 2791 of the Public Health Service Act (42 U.S.C. 300gg–91), section 733 of the Employee Retirement Income Security Act (29 U.S.C. 1191b), and section 9832 of the Internal Revenue Code [26 U.S.C. 9832], as applicable.”

§300gg–19 Appeals Process