Affordable Care Act Internal Claims and Appeals and External review Disclosures.
Revision of a currently approved collection
No
Emergency
03/18/2022
03/10/2022
table that charts list comparision
Requested
Previously Approved
6 Months From Approved
07/31/2024
190,913
278,412
1,621
2,271
813,839
1,143,236
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.
The Department of Laborâs Employee Benefit Security Administration (EBSA), in conjunction with the Office of Personnel Management (OPM), the Department of The Treasury, Internal Revenue Service (IRS), and the Department of Health and Human Services (HHS), issued a joint Interim Final Rule (IFR), Requirements Related to Surprise Billing; Part II, which implements provisions of the No Surprises Act. The No Surprises Act was enacted on December 27, 2020, as title I of Division BB of the Consolidated Appropriations Act, 2021. The No Surprises Act establishes new protections from surprise billing and excessive cost-sharing for consumers receiving health care items and services. Section 102 of the No Surprises Act contains limitations on cost sharing and requirements for initial payments for emergency services. Section 103 establishes a federal independent dispute resolution (IDR) process that allows plans and issuers and out-of-network providers to resolve disputes on out-of-network rates. Section 105 contains limitations on cost sharing and requirements for initial payments for air ambulance services, and allows plans, issuers, and providers of air ambulance services to access the federal IDR process. The IFR implements many of the lawâs requirements for group health plans, health insurance issuers, carriers under the Federal Employees Health Benefits (FEHB) Program, health care providers and facilities, and air ambulance service providers. The requirements in the No Surprises Act apply for plan years (in the individual market, policy years) beginning on or after January 1, 2022.
The Secretaries and OPM Director have determined that it would be impracticable and contrary to the public interest to delay putting the provisions in these interim final rules in place until after a full public notice and comment process has been completed. Although this effective date may have allowed for the regulations, if promulgated with the full notice and comment rulemaking process, to be applicable in time for the applicability date of the provisions in the No Surprises Act, this timeframe would not provide sufficient time for the regulated entities to implement the requirements.
It has been determined that this information must also be collected prior to the time periods established under Part 1320 of the Paperwork Reduction Act (PRA) and that this information is essential to the mission of EBSA to implement the provisions of the No Surprises Act.
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 decrease the hour burden by 650 hours compared with the prior submission and decrease the cost burden by $329,397 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.
Emergency Justification Memo 1545-2182_signed.pdf
1545-2182 SS_IFR2_AG.docx
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