Self-insured compliance guidance for appeals & reviews

Non-grandfathered self-insured plans for the first time have detailed, prescriptive claims appeals and review processes they must comply with, and if a plan does not strictly adhere with those procedures, its determination can be summarily reversed, a Thompson news alert last week said.

Employee Benefits Security Administration (EBSA) Technical Release 2010-01 provides an enforcement safe harbor for non-grandfathered self-insured group health plans, normally not subject to state rules but covered under federal ones. Under the interim safe harbor, agencies implementing health reform will not take enforcement action against a self-insured group health plan that complies with either:

• state external review processes -- self-insured plans may choose to voluntarily comply with state external review provisions; or
• the methods described in the technical release, which are based on the Uniform Health Carrier External Review Model Act promulgated by the National Association of Insurance Commissioners (NAIC).

The technical release also describes in detail the procedures and deadlines for self-insured group health plans regarding various stages of standard reviews and expedited reviews.