Bulletin 2011-04 Compliance with External Review Requirements of the Patient Protection and Afforda

To: From: Subject: Date: I. South Carolina Department of Insurance Bulletin Number 2011-04 and Health '\IKKI R. HALEY Governor DA\ID BLACK I>ireetor of Insurance health insurance Independent Review Agents Organizations and South Carolina certified Private David Director Compliance with the External Review Requirements of the Patient Protection and Affordable Care Act July 5, 2011 Purpose The purpose of this Bulletin is to inform all licensed insurers and health maintenance organizations issuing health insurance coverage ("health insurance issuers"), certified Independent Review Organizations and Private Review Agents of the procedures compliance with the review requirements the Patient Protection and Affordable Act (PPACA). II. Overvien msurance Technical Release 11 Health and Human intends to n•\,lr'U! implementation no later than July 31. The requirements external review set forth in section 19 of the PHSA and related regulations apply to all new or renewed health insurance coverage, unless the health insurance coverage is a grandfathered health plan as such term is defined in Section 1 I of the PHSA. Therefore, pursuant to 11 0( I), effective July 31, 2011, all health insurance issuers, certified Independent Review Organizations and Private Review Agents must adopt the new standards for all new or renewed health insurance coverage, unless the health insurance coverage is a grandfathered health plan. in order to comply with the temporary external review requirements of the Patient Protection and Affordable (PPACA) and to avoid preemption by the federal law. Grandfathered health plans may either comply with current South Carolina law or the new standards. Current South Carolina standards external remain in eftect where they do not conflict with the provisions of PPACA. III. External Review Guide 31' II Assignment ofthe Independent Review Organization appeals be adverse determination pursuant to 38-71-1940. 3 1- I 980: For a request for an expedited external review, within 15 days of receipt of a notice of an adverse detennination. 3 8-7 I -1970: Provides that the insurer will assign an independent review organization from a list of approved IROs maintained by the Department. internal appeal process be lUUJl\.U • the to the requirements of CFR I 13 6(b )( 2) with respect to the related claim or internal appeal or the issuer the internal appeal four notice determination of rece1vmg an adverse has been made under the insurer's internal appeal process. For a request for an expedited external review no time frame deadline. Insurers shall notify the Department of a request for external review and assignment of an IRO. The Department shall assign to the insurer an IRO for each case based upon a rotational system. The rotational \'>·ill independent Timeframes for decision day timeframe, the information shall be considered in the review and shall be forwarded to the insurer within one business day of receipt by the IRO. 1-1980: Immediately For an expedited external upon making the decision review, the time shall not relating to a request for an exceed hours from expedited external review. receipt of the request For a standard external review, the time period shall not exceed 45 days from The U.S. Departments of Treasury, Labor and Health and Human Services have issued model notices (available at that provide a template for the disclosures that should be made regarding external (e.g., contact and timeframes initiating an All Independent Review Organizations must be accredited by a nationally recognized private accrediting organization. IV. Questions: contents ofthis Bulletin be directed to: Deputy Director South Carolina Department of Insurance l King Street Suite sc 1