Federal External Review Process

Non grandfathered self-funded group health plans & health insurance coverage are subject to the federal requirements outlined by the Department of Labor DOL. Innovation Health will administer this process on behalf of our self-funded plan sponsors upon request as an extension of their administrative services contract.  Your plan documents will provide a description of the applicable external review process.

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

In some situations you may not be required to exhaust the internal appeals process if:

• The plan waives the exhaustion requirement;
• The plan is considered to have exhausted the internal appeal process by failing to comply with the requirements of the internal appeals process except those failures that are based on de minimus violations that do not cause, and are not likely to cause, prejudice or harm to the covered person; or
• The covered person simultaneously requests an expedited internal appeal and an expedited external review.

After exhausting the applicable appeal process, you or your 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 independent review Organization (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 Innovation Health & the covered person except to the extent 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 person’s 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.
• A covered person is not charged a fee for an external review under the federal process.
• For those covered under a state mandated review a filing fee of not more than $25 may be applicable.

Members can call the Member Services toll-free number listed on their ID card if they have any further questions regarding external review. Plan sponsors and producers; please contact your Innovation Health representative for additional information.

Certain benefit plans may not be subject to the requirements of the Patient Protection and Affordable Care Act (ACA), such as Self funded Traditional grandfathered plans and exempt plans. These plans have the option of participating in Innovation Health’s Company Sponsored External Review program.