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.
Breaking Down Health Plans, HSAs, AI With Paul Fronstin of EBRI
November 19th 2024Featured in this latest episode of Tuning In to the C-Suite podcast is Paul Fronstin, director of health benefits research at EBRI, who shed light on the evolving landscape of health benefits with editors of Managed Healthcare Executive.
Listen
In this latest episode of Tuning In to the C-Suite podcast, Briana Contreras, an editor with MHE had the pleasure of meeting Loren McCaghy, director of consulting, health and consumer engagement and product insight at Accenture, to discuss the organization's latest report on U.S. consumers switching healthcare providers and insurance payers.
Listen