Within the Health Care Reform structure there is a provision that adds an external appeals component to claims processing.  In the mad rush to get regulations and guidance in place before the September 23, 2010, start date, the department of Labor issued a Fact Sheet on the appeals process.  It references interim regulations  which in tun references the Uniform Health Carrier External Review Act produced by NAIC(National Association of Insurance Commissioners).

Now the way it is set up, the regs suggest that States adopt the NAIC model for insurance written in their states.  For group health plans not subject to state regulation, or for insurance issued in states that have not adopted the NAIC model, a federal external appeals process will apply.  However, the actual process itself is not yet defined, and is not required to be fully defined until July 1, 2011.  So as best as I can tell, the idea is that the external appeals process is just that, an appeal that occurs outside of the plan.  It is ideally governed by the state insurance appeals process and models give by the NAIC.  And I would assume that the federal model eventually adopted will look like the NAIC recommendations.

So what does this mean?  Well, we still have to wait.  But for now it means they are working on it.  Plan sponsors should take a look at the NAIC model process available and recognize that they should start evaluating the process to see how they would ultimately implement such an external appeals process once actual guidance is finally issued.