Affordable Care Act Internal
Claims and Appeals and External Review Procedures for ERISA
Plans
Revision of a currently approved collection
No
Emergency
10/04/2021
10/01/2021
Requested
Previously Approved
6 Months From Approved
05/31/2022
190,913
329,980
1,621
2,816
813,839
1,381,946
This collection of information request
includes the information collection and third party notice and
disclosure requirements that a plan must satisfy under final
regulations implementing provisions of the Affordable Care Act
pertaining to internal claims and appeals, and the external review
process. The No Surprise Act extends the balance billing
protections related to external reviews to grandfathered plans. The
definitions of group health plan and health insurance issuer that
are cited in section 110 of the No Surprises Act include both
grandfathered and non-grandfathered plans and coverage.
Accordingly, the practical effect of section 110 of the No
Surprises Act is that grandfathered health plans must provide
external review for adverse benefit determinations involving
benefits subject to these surprise billing protections.
Grandfathered and non-grandfathered plans must provide claimants,
free of charge, any new or additional evidence considered, relied
upon, or generated by the plan or issuer in connection with the
claim, and the requirement to comply either with a State external
review process or a Federal review process. The disclosure
requirements of the Federal external review process require (1) a
preliminary review by plans of requests for external appeals; (2)
Independent Review Organizations (IROs) to notify claimants of
eligibility and acceptance for external review; (3) the plan or
issuer to provide IROs with documentation and other information
considered in making adverse benefit determination; (4) the IRO to
forward to the plan or issuer any information submitted by the
claimant; (5) plans to notify the claimant and IRO if it reverses
its decision; (6) the IRO to notify the claimant and plan of the
result of the final external appeal; 7) the IRO to maintain records
for six years.
Before January 1, 2022,
grandfathered health plans must provide external review for adverse
benefit determinations involving benefits subject to these surprise
billing protections. If normal clearance procedures are followed,
this statutory deadline may be missed and the external review
provisions will not be available with its accompany
protections.
The No Surprise Act extends the
balance billing protection related to external reviews to
grandfathered plans. Under Section 110 of the No Surprises Act,
grandfathered health plans must provide external review for adverse
benefit determinations involving benefits subject to these surprise
billing protections. Adjustments to the burden estimates result
from updated estimates on the number of ERISA-covered plans and
policyholders and increases in wage rates and postage rates. These
updated data inputs increase the hour burden by 425 hours compared
with the prior submission and increase the cost burden by $245,732
compared with the prior submission.
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.
Interim Procedures for Federal External Review and Model Notices Relating to Internal Claims and Appeals and External Review under the Patient Protection and Affordable Care Act