ACA Facts: Internal and External Appeal of Denials

December 28, 2012

Internal and External Appeals of Denials

The ACA, in order to protect against capricious decisions by health plan providers, implements an improved appeals process, offering both an internal and external process.   Under the regulations, all consumers enrolled in new health plans have access to a standard appeals process that ensures full and fair review of the health plan's decision.  First, each plan must include an internal appeals process for its consumers who are denied coverage; which at a minimum provides information about the grounds for denial, notifies patients of their right to appeal, and ensures a full and fair review of the claim.   It must also offer an expedited review process in cases of emergencies.  Additionally, if the appeal is denied by the health plan, the consumer has the right to appeal to an outside, independent decision-maker in their state.