Aetna External Review Program

 On March 23, 2010 President Obama signed the Patient Protection and Affordable Care Act (PPACA) into Law.

In compliance with (PPACA) in accordance with the Uniform Health Carrier External Review Model Act (NAIC Uniform Model Act) on external review, independent review of coverage denials based upon lack of medical necessity or the experimental or investigational nature of the proposed or rendered service or supply, adverse coverage determinations, or recisions, plans must have an external review process. The requirements of the external review process are dependent upon whether a plan is subject to the “state standard” or the federal standard” under the interim final regulations.

All non-grandfathered plans (self-funded, insured, group & individual) are subject to some form of external review process. The interim final regulations provide for both a state and federal standard for external review. If you participate in a Self Funded HMO benefit plan you will automatically be provided external review rights at the final level of appeal.

States that have an external review process that meets, at a minimum, the consumer protections set forth in the interim final regulations will meet the state standard for external review under PPACA. Health insurers must comply with the state external review process in those states.

In states that do not have external review legislation, the Department of Health & Human Services has established an interim federal process that will be administered by the Office of Personnel Management (OPM). This interim process applies to all individual policies and fully insured group health plans.  The following states & territories do not have external review legislation:

• Alabama,   Mississippi, Nebraska, Puerto Rico, Guam, U.S. Virgin Islands and U.S. Samoa.

The standard external review process for self funded group health plans & health insurance coverage will follow the interim process outlined by the Department of Labor (DOL). Aetna will administer this process for our self funded plan sponsors upon request as an extension of their administrative services contract.

If, upon final level of review, the Plan upholds the coverage denial and it is determined that the member is eligible for external review, he or she will be informed in writing of the next steps necessary to request an external review and a request for External Review form will be included with the letter.

Federal External Appeal process

Members subject to the interim Federal External Review appeal process are not charged a fee for their review. A standard Federal External Review, will be completed, within no more than 45 days after the receipt of the request for external review by the Independent Review Organization (IRO), the IRO must provide written notice to the member & the health plan of its decision.

For Expedited cases, the decision must be provided as expeditiously as possible, but no later than 72hrs after receipt of request.

After exhausting the applicable appeal process, a member or their authorized representative will have four months from the date of receipt of a notice of an adverse determination or final adverse determination to request an external review.

• Notification of eligibility will be sent in writing within 5 business days of receipt of the request.
• You may submit additional information you wish to be considered to the IRO within the timeframe designated in the correspondence.
• The IRO is required to perform a “de novo” review which means without giving deference to the plan’s internal appeals decision making process.
• Within 45 days after the date of receipt of the request for external review the IRO will provide written notice specifying whether the plan’s determination is upheld or reversed, and briefly specify the basis for the determination in accordance with plan documents.
• The decision of the IRO is binding on Aetna & the covered person except to the extent that other remedies are available under applicable state law.
• Expedited reviews are available if the covered person has a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered persons ability to regain maximum function; or if the final adverse determination concerns an admission, availability of care, continued stay or health care services for which the covered person received emergency services, but has not been discharged from a facility.