Blog 8/2/2019

HHS Announcement: Adverse Benefit Determination Language Must Be Updated

For certain “adverse benefit determinations,” such as claim denials, plan participants in self-insured health plans are entitled to request a federal external review. Fully insured plans can also opt in to this process as well.

On July 12th, the United States Department of Health and Human Services (HHS) announced that MAXIMUS, the federal contractor that administers this review process on behalf of the HHS, now offers an online portal for requesting an external review. To accommodate this change, the HHS has determined that notices of adverse benefit determination and final internal adverse benefit determination must be updated to note this new feature.

The updated notices must provide:

  • The web address for the portal
  • Explain how to submit requests online
  • Information about submitting external review requests by mail or fax
  • State that expedited review may be requested via the online portal, phone, or email.

For example, the updated notice might look like this:

“You can request an external review by:

  • Submitting your request online at externalappeal.cms.gov, under the ‘Request a Review Online’ heading,
  • Faxing your written request to 1-888-866-6190, or
  • Sending it by mail to: MAXIMUS Federal Services, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534.

If you believe your case should be expedited, you can select “expedited” if submitting the review request online, by emailing FERP@maximus.com, or calling Federal External Review Process at
1-888-866-6205 ext. 3326.”

Note that the HHS is requiring plans and insurers to electronically submit samples of their updated notices to the HHS. Since the portal is already active, plans should probably address this sooner rather than later.

For more information, you can review the technical guidance here: https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Technical-Guidance-Update-FERP-URL-Correction.pdf

 

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