By regulating the UM process, state and federal governments are able to limit perceived abusive or overly restrictive practices and create a rubric through which patients obtain their benefits. However, the current UM system varies greatly from state to state. Our goal is to facilitate stakeholder’s access to and understanding of these complex UM rules and regulations by providing a clear and concise state guide. The UM module focuses on several key components of these regulations, including: scope, regulatory contacts, licensure requirements, program requirements, reviewer qualifications, appeals processes and other relevant information.
Under the ACA, group health plans and health insurance issuers offering coverage in group and individual markets must comply with external review (ER) process requirements. Compliance with state and federal ER laws is a complicated endeavor. RegQuest’s External Review module provides a functional summary of all state ER laws and regulations and analyzes differences between state law and the NAIC Uniform Health Carrier External Review Model Act.
As opposed to utilization management appeals that are based on a determination of medical necessity, grievance appeals pertain to the availability, delivery, or quality of health care services, claims payment or reimbursement for health care services, or matters pertaining to the contractual relationship between a covered person and a health carrier. RegQuest aims to provide a detailed overview of state grievance requirements including: scope, regulatory contact information, licensure requirements, program requirements, reviewer qualifications, appeals process and other relevant information.