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Pennsylvania Provides Clarification of External Review Process

Notice 2014-11 issued September 27, 2014 explains that health insurance issuers are required to comply with the federal external review process. The notice explains which issues are still reviewed by the state, and clarifies that a "denial of a benefit" includes a denial of a pre-service authorization involving medical judgment. It also clarifies that "failures to provide or make payment in whole or in part for a benefit" include circumstances in which a contractual issue relates to the amount of payment, such as, but not limited to, situations in which claimants are getting less than 100% of their claims (including co-pay) paid by their issuers. Notice 2014-11 concludes that consumer complaints relating to pre-service authorization denials based on medical judgment, as well as consumer complaints relating to the amount of a payment should be handled pursuant to the federal external review process. It also lists the types of complaints that should continue coming to the Pennsylvania
Insurance Department. Notice 2014-11 can be found by clicking here.


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