CMS-10338 Email response to plans and issuers electing HHS process

DEPA RTM EN T OF H EA LTH & H UM A N SERVICES

Centers for Medicare & Medicaid Services

200 Independence Avenue SW
Washington, DC 20201

December 2011

Thank you for informing us that you are electing the HHS-administered process for external
review. The instructions in the “Technical Guidance for Interim Procedures for Federal External
Review Relating to Internal Claims and Appeals and External Review for Health Insurance
Issuers in the Group and Individual Markets under the Patient Protection and Affordable Care
Act” will provide you with next steps in this process. This guidance was originally published on
August 26, 2010 and is available at:
http://cciio.cms.gov/resources/files/interim_appeals_guidance.pdf. Specifically, you should
follow the information under “Interim Federal External Review Process for Health Insurance
Issuers in the Group and Individual Markets” (under Roman Numeral II beginning on page 4)
with the following changes:
1) In accordance with the interim final rules implementing section 2719 of the PHS Act
on July 23, 2010 (as amended on June 24, 2011), external review is available for adverse benefit
determinations and final internal adverse benefit determinations by a plan or issuer that involves
medical judgment (including, but not limited to, those based on the plan’s or issuer’s
requirements for medical necessity, appropriateness, health care setting, level of care, or
effectiveness of a covered benefit; or its determination that a treatment is experimental or
investigational), as determined by the external reviewer; and a rescission of coverage (whether or
not the rescission has any effect on any particular benefit at that time). (See 45 CFR
§147.136(d)(1)(ii)(A)) These definitions of adverse benefit determinations and final internal
adverse benefit determinations replace the language in the technical guidance.
2) The information requested to be sent to [email protected] on page 5 of this
technical guidance should now be sent to [email protected] and electronically
copied to [email protected] and should be sent by the earlier of January 1, 2012 or the
date by which you are using the HHS-administered process. This information includes:
1.
The products which are subject to the HHS-administered process
2.
Contact information for designated personnel in the appeals department of the
issuer, plan or third party administrator including:
- Name(s)
- Mailing address(es)
- Telephone number(s)
- Facsimile number(s)
- Electronic mail address(es).

3.

In addition, contact information for a designated individual who will be available
to address urgent care cases outside of normal business hours (including
weekends and holidays).

Please submit any questions to [email protected].
Thank you very much,

Ellen Kuhn
Director, Appeals Division
Consumer Support Group
Center for Consumer Information and Insurance Oversight
Centers for Medicare and Medicaid Services
U.S. Department of Health and Human Services

OMB Control Number 0938-1099

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