Internal and External Review

For plan years beginning on or after September 23, 2010, non­-grandfathered health plans must comply with new claims procedures, including improved internal claim review procedures and a new requirement for external review. Insured plans must comply with state external review processes. Self­-funded plans (or insured plans in states that do not have external review laws) must comply with new federal external review rules.

Note: The internal and external claims review standards only apply to certain types of health plans, such as major medical insurance.

Under the ACA statute and federal agency guidance published to date, they do not apply to HIPAA excepted benefits, such as disability, cancer, hospital indemnity, or accident insurance. Click here for more information about the types of benefits that are exempt from the ACA plan design mandates.

Neither American Fidelity Assurance Company nor American Fidelity Administrative Services provides tax or legal advice and, given the complexity of these laws, we always recommend working with your legal counsel on how the laws impact your specific situation.