The Patient Protection and Affordable Care Act (PPACA) is extending new appeal protections which will make it easier for providers to assist patients with denied medical claims.

The law provides consumers with a way to appeal coverage determinations or claims to their insurance company and establishes an external review process. These changes are effective for health plans beginning on or after September 23, 2010.

The PPACA mandates stricter appeal review and disclosure guidelines which are expected to affect claim denials related to medical necessity, experimental/investigational, emergency care, maximum benefits and usual, reasonable and customary calculations.

The law seeks to simplify the appeal process by providing federal requirements applicable to all plans. Carrier will be required to provide an internal appeal review process in compliance with state appeal review or ERISA regulations and an external review process in compliance with state external review law or the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners (NAIC).

The AppealLettersOnline.com August newsletter will feature instructions on using PPACA protections in appeals and will provide a number of new letters citing the extended protections.  Be sure to signup as a member so that you have access to this information.