Claims Appeal External Review Procedures in Health Insurance

Learn about external review of adverse determinations involving claims for payment for healthcare services under commercial health insurance policies. Gain insights on the mechanism that must be in place to allow for review of denied healthcare claims. Understand how the National Association of Insurance Commissioners (NAIC) Uniform Health Carrier External Review Model Act (Model Act) serves as the foundation for federal and state external review requirements. Assess the interaction between the Model Act and the Patient Protection and Affordable Care Act (ACA), the latter of which requires insurers to provide an external review opportunity. Consult this practice note for guidance on issues including providing notice of external appeal rights and insurer policies and procedures.

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