External Review Medical Judgment

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HHS-Administered Federal External Review Process for …

https://www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/csg-ext-appeals-facts

The HHS-Administered Federal External Review Process applies to “adverse benefit determinations,” including those that involve medical judgment (including, but not limited to, those based on the plan’s or issuer’s requirements for medical necessity, …

External Review | HealthCare.gov

https://www.healthcare.gov/appeal-insurance-company-decision/external-review/

Preserving Meaningful External Review Despite Insurers’ …

https://blog.petrieflom.law.harvard.edu/2021/05/07/medical-necessity-rules-external-review/

Instead, federal regulations should make clear that the ACA requires external reviewers to apply traditional, standard-based, definitions of medical necessity when …

What is external review? - OPM.gov

https://www.opm.gov/frequently-asked-questions/insure-faq/multi-state-plan-program/what-is-external-review/

What is external review? Multi State Plan Program Questions and answers What is external review? External review is the process by which OPM, or an Independent …

Insure FAQ - What is external review? - U.S. Office of …

https://www.opm.gov/faq/insure/What-is-external-review.ashx

External review is the process by which OPM, or an Independent Review Organization if the case requires medical judgment, reviews a health insurance plan’s decision to deny …

Federal External Review - Understanding the Process

https://www.mrioa.com/federal-external-review-understanding-process/

When a claim or prior authorization request is still denied after all internal appeal levels have been exhausted, the Affordable Care Act permits the claimant …

DEPARTMENT OF HEALTH & HUMAN SERVICES

https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/FERP-Guidance-8-29-2018.pdf

1. Request for external review. A claimant or authorized representative (“claimant”) may file a written request for an external review with the external review …

Internal Claims and Appeals and the External …

https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/Appeals%20presentation%204.2.18_comments%20incorp_CMS%20%28002%29_508_Final.pdf

Scope of Claims Eligible for Federal External Review Applies to adverse benefit determinations (ABDs) (or final internal ABD) involving: Medical judgment INCLUDING, …

45 CFR § 147.136 - Internal claims and appeals and …

https://www.law.cornell.edu/cfr/text/45/147.136

(i) If a State external review process that applies to and is binding on a health insurance issuer offering group or individual health insurance coverage includes at a minimum the …

A Consumer’s Guide to Navigating the External Review …

https://www.nairo.org/assets/docs/NAIRO-Issue-Brief-A-Consumer%E2%80%99s-Guide-to-Navigating-the-External-Review-Options-Under-the-New-Insurance-Marketplace.pdf

offering non-grandfathered plans in the state must provide external review via one of two options: 1) Utilizing the HHS-administered federal external review process or 2) …

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