For more than thirty years, ERISA health insurance plans had to provide for an internal administrative review of health benefit claim denials, a process that a claimant had to pursue before bring suit in federal court for a health claim denial. The ACA added a significant improvement in the existing, pre-litigation review process for ERISA health plan denials. It requires plans to offer an external review process for health insurance benefit denials, conducted by an independent third party. The external review process is available when the denial involves application of medical judgment such as medical necessity, level of care, and experimental or investigational treatment, and whether the health care setting (out-patient, or intensive out-patient, or residential treatment) is appropriate. I have found the process particularly useful in appealing denials of residential treatments for eating disorders or substance abuse treatment for teens. The external review process occurs after you have exhausted the plans administrative appeals. In addition to the claim file, the external review will consider new arguments and documents you submit with the request, so the request should be carefully completed to make it as effective as possible.
In my Connecticut ERISA appeal practice, I have found the process particularly useful in appealing denials of residential treatments for eating disorders such as bulimia or anorexia or drug or alcohol substance abuse treatment for teens. Connecticut does not have facilities offering residential treatment in these areas, so doctors and parents want to send teens to out-of-state programs.
Connecticut has been a leader in implementing the ACA, so it is not surprising that Connecticut has established a good external review process. The external review process is conducted by the Connecticut Department of Insurance. Click here to go to the site. A Connecticut ERISA benefits lawyer, familiar with Connecticut’s procedures, can be a big help in preparing an effective request for external review.
An important thing to remember about external review is the deadline is 120 days after the denial. The regular time to appeal ERISA denials is either 60 days, or more commonly, 180 days, so make sure you, or your ERISA attorney, are aware of the difference.
Because of the external appeal process established by the ACA, at least with health insurance claim denials, the insurance company does not have the last word before you have to bring suit.