CMS-10338 - Sub-regulatory Guidance (related to Nonsubstantive change request)

U.S. Department of Health and Human Services
Centers for Medicare and Medicaid Services
Center for Consumer Information and Insurance Oversight
Washington, D.C. 20201
TECHNICAL GUIDANCE- FEBRUARY 20, 2015
DATE:

FEBRUARY 20, 2015

SUBJECT:

INSTRUCTIONS FOR SELF-INSURED NON-FEDERAL GOVERNMENTAL
HEALTH PLANS AND HEALTH INSURANCE ISSUERS OFFERING GROUP AND
INDIVIDUAL HEALTH COVERAGE ON HOW TO ELECT A FEDERAL EXTERNAL
REVIEW PROCESS

This technical guidance sets forth instructions regarding the election of a Federally-administered
external review process using the Health Insurance Oversight System (HIOS). This technical
guidance applies to health insurance issuers offering group and individual health coverage that
are using a Federally-administered external review process in accordance with Technical Release
2011-02 (TR 2011-02), available on the CCIIO website. 1 This technical guidance also applies to
self-insured, non-federal governmental health plans and amends prior technical guidance
pertaining to such plans that was released on June 22, 2011. 2 These provisions do not apply to
plans and issuers in connection with grandfathered health plans.
I.

Election of a Federal External Review Process

For guidance related to the election of a Federal external review process by self-insured nonfederal governmental plans, and issuers in the group and individual market in States whose
external review processes are found not to meet the requirements to be an NAIC-parallel process
or an NAIC-similar process, refer to TR 2011-02 and prior technical guidance released on June
22, 2011.
Previous guidance required information regarding this election to be sent to HHS via an email
address. This technical guidance now requires health insurance issuers and self-insured, nonfederal governmental plans using a Federally-administered external review process to submit
information regarding their election of a Federal external review process to HHS via HIOS by
the date on which such plans and issuers intend to begin using the Federal external review
process. 3 If there are any changes at any time after the election is first submitted, plans and

1

Technical Release 2011-02: Guidance on External Review for Group Health Plans and Health Insurance Issuers
Offering Group and Individual Health Coverage, and Guidance for States on State External Review Processes,
available at http://www.cms.gov/CCIIO/Resources/Files/Downloads/appeals_srg_update.pdf
2
Prior technical guidance for self-insured non-Federal governmental health plans, released on June 22, 2011 is
available at http://www.cms.gov/CCIIO/Resources/Files/Downloads/hhs_srg_elections_06222011.pdf.
3
If a plan or issuer has previously provided this information and there have not been any changes, no further action
is required at this time.

issuers must update their election information in HIOS as soon as possible. As described in 45
CFR 147.136(b)(2)(ii)(E) and 45 CFR 147.136(b)(3)(ii)(E), all notices to individuals in the
internal claims and appeals process must include a description of available internal appeals and
external review processes, including information regarding how to initiate an appeal. If the selfinsured nonfederal governmental plan or issuer is participating in the HHS-administered external
review process, such notices must inform the claimant that the claimant can request an external
review in writing by sending it electronically to the HHS-administered external review
Contractor. The current Federal contractor contact information is available at
http://www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/csgext-appeals-facts.html.
II.

Instructions for Electing a Federal External Review Process within HIOS

To begin this process, applicants will need to register for access to HIOS, request access to the
External Review Election Module, and choose the Submitter role for their submission. The
Submitter is the person who completes the application and submits the election information
a. New HIOS users:
i. New HIOS users will need to use the Enterprise Portal to register in the
Enterprise Identity Management (EIDM) system at https://portal.cms.gov
before they can become a HIOS user. Click on “New User Registration” in
the right column of the web page under “Login to Secure Portal” and
follow the instructions. Users will receive an email confirmation that
registration has been completed, along with their EIDM User ID.
ii. Once the user receives an EIDM User ID, the user should log back into
EIDM at https://portal.cms.gov, using their EIDM User ID and password.
Click on the “Login to CMS Secure Portal” button in the right column of
the webpage. Click on the “Request Access Now” link on the right column
of the webpage. Select “Request New Application Access” from the left
side of the screen. Select HIOS from the “Application Description”
dropdown box. New users will need to register in HIOS by clicking the
link at the bottom of the page and following the registration instructions.
Once the HIOS registration has been approved, the user will receive an
email with their HIOS information and an Authorization Code.
iii. The user will need to log into EIDM at https://portal.cms.gov and click on
the “Login to CMS Secure Portal” button in the right column. Click on the
“My Access” option located in the dropdown under the user name in the
upper right hand corner of the screen to “Request New Application
Access” and choose “HIOS.” Enter the HIOS Authorization Code
provided in the confirmation email and follow the instructions. The user
will need to logout of EIDM then log back in to EIDM at
https://portal.cms.gov and navigate to the HIOS tab in the upper left
corner. Once the user navigates to the HIOS tab, they will click the

“Access HIOS” link and request access to the HIOS External Review
Election Module by navigating to “Role Management.” Follow the
instructions to complete the request.
iv. If the user cannot locate their issuer organization or the non-federal
governmental plan within Role Management, they should navigate to the
“Manage Organization” page on the HIOS home page and follow the steps
to create a new organization. After successfully registering the
organization, the user can then request the appropriate role within the
HIOS External Review Election module and associate with an
organization.
b. Existing HIOS Users:
i. Existing HIOS users should log in to EIDM at https://portal.cms.gov and
click to the HIOS tab. Once on the HIOS home page, they can navigate to
the Role Management functionality to request the Submitter role for the
HIOS External Review Election module and associate that role with an
organization.
ii. If the user cannot locate their issuer organization within “Role
Management,” they should navigate to the “Manage Organization” page
on the HIOS home screen and create a new organization (either issuer or
non-federal governmental plan). After successful organization
registration, the user may request the appropriate role within the HIOS
External Review Election Module.
After completing the online request for the appropriate role, users will receive an email
notification once access to the module has been approved. Once organization registration and
role request are approved, authorized users with the appropriate submitter role may access the
module and submit their external review election. A copy of the HIOS External Review Election
module User Manual is available for download once you access the External Review Election
module in HIOS. If you have any questions regarding accessing HIOS, please contact the help
desk at [email protected] or 1-855-CMS-1515.