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Recent amendments apply standards of external review
Regulations were designed to provide uniform federal standards to govern consumers' right to appeal denials of claims or coverage by health plans.
Generally, courts require litigants to exhaust all administrative remedies before seeking judicial intervention. Thus, a claimant would be required to exhaust a plan's internal review processes before resorting to external review. Under the 2010 regulations, however, this administrative exhaustion requirement was relaxed such that a claimant could immediately seek external review of benefit denials if the plan failed to "strictly adhere" to all of the regulations' requirements for internal claims and appeals processes.
This amendment effectively removes the "strict" from "strict adherence" and perhaps is more indicative of a "substantial adherence" standard.
DC Roundtable: Patrick Cooney of The Federal Group Drops the Latest on PBM Legislation in Washington
April 11th 2024In this episode of "DC Roundtable," Peter Wehrwein, managing editor of Managed Healthcare Executive, spoke with Patrick Cooney, president of The Federal Group, a lobbying and strategic planning firm in Washington, D.C., about recent developments in Washington concerning PBMs.
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