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FAQs for Claimants

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 CONSUMER INFORMATION

 

1.     What is the External Review Process?



The External Review Process gives you the right to an independent, third-party review when your health insurance plan denies care or refuses to pay for care you already received. Under the Affordable Care Act, health insurance issuers in certain States (which have not met minimum consumer protections in their external review process) may choose either:  the HHS-Administered Federal External Review Process, or they may contract with accredited Independent Review Organizations (IROs) to review external appeals on their behalf.







2.     Under the HHS-Administered Federal External Review Process, who may request external review?





A consumer (or patient) or their authorized representative may request an external review.







3.    
When can I request an external review?







A consumer (or their authorized representative) must request an external review within 4 months of receiving a final internal adverse benefit determination notice from their health plan or issuer. 







4.    
Are there times when I can request a simultaneous internal appeal and external review?





Yes, you may request a simultaneous internal appeal and external review: 







When an adverse benefit determination involves a medical condition of the claimant for which the timeframe for completion of an expedited internal appeal would seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, 







When a final internal adverse benefit determination involves a medical condition of the claimant for which the timeframe for completion of an expedited internal appeal would seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, or







When a final internal adverse benefit determination concerns the admission, availability of care, continued stay or health care service for which the claimant received emergency services but has not yet been discharged from a facility.







5.    
How can I appoint an “authorized representative” for my external appeal?







You can designate an authorized representative (such as your physician) to request an external appeal by completing an “Appointment of Representative” Form. You must complete and sign Section 1 of the form and the individual you are appointing must complete and sign Section 2 of the form.  You should keep a copy of the signed form and include the signed original with your review request.

The HHS-Administered Federal External Review Process “Appointment of Representative” Form is available by fax or e-mail request, and it is available at:  www.externalappeal.com.







In addition, your health plan or issuer, or Consumer Assistance Program in your home State may have an Appointment of Representative form.  If so, you may submit a copy of that form with your request for external review (provided all the information required by the HHS form is contained in this
form).







6.    
Can a provider submit an external appeal on its own behalf?





No.  A provider may not submit an external appeal directly, but may serve as an authorized representative for a patient.







7.    
How much does an external review cost under the HHS-Administered Federal External Review Process?





There is no cost to you or the insurer.







8.     Who operates the HHS-Administered Federal External Review Process?





MAXIMUS Federal Services, Inc. was selected as the independent, third party reviewer to operate the HHS-Administered Federal External Review Process.







9.    
Who conducts the external review?





MAXIMUS has a group of experts, including lawyers, doctors, nurses and other consultants, who conduct the external review.







10. 
How can I ask for an external review under the HHS-Administered Federal External Review Process?





You can mail or fax a written request for a standard external review. Starting soon, you will also be able to use a secure web-based portal to request a standard external review.





You can ask for an expedited external review by calling the toll-free telephone number: 1-888-866-6205. You can ask for an expedited external review by mail or fax.





You can mail a request to the address listed on the notice provided by the health insurance issuer denying benefits or you can mail your request directly to MAXIMUS.







By Mail:

MAXIMUS Federal Services



3750 Monroe Avenue, Suite 705



Pittsford, NY 14534








By Fax:
1-888-866-6190











11.  Can I ask for an external review by phone?







Only requests for expedited (fast) external review can be made by phone. Standard requests must be submitted in writing (mail or fax) or online (starting soon).







12.  How long does it take MAXIMUS to make an external review decision for the HHS-Administered Federal External Review Process?







For a standard external review, the MAXIMUS reviewer must give you written notice of the decision as soon as possible, but no more than 45 days after the reviewer receives your request for an external review.







For an expedited external review, the MAXIMUS reviewer must give you and the health plan the decision as quickly as medical circumstances require, but no more than 72 hours of receiving your request. The reviewer can give you an oral decision but must follow up in writing within 48 hours.







13.  Where can I get more information about the HHS-Administered Federal External Review Process?







You can get more information on this website and at these other websites:







www.cms.gov.cciio





https://www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/External-Appeals.html

 

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