RegQuest offers one stop shopping to track key state and federal requirements impacting the appeals process, including the new external review (ER) module.

As consumers take on a more active role in their health care decisions, the importance of external review has grown.  In addition, the external review market segment is growing, as reviewers must now comply with state law and those changes implemented by the Affordable Care Act (ACA).  Regulators, payors, providers and others will be using RegQuest to track and understand the array of regulations and how the ER process works when an adverse determination is made by health plans.

Under the ACA, group health plans and health insurance issuers offering coverage in the group and individual markets must comply with ER process requirements.  Many states have implemented ER systems that parallel the National Association of Commissioners (NAIC) Uniform Model Act, although some states simply offer access to the Federal External Review Process.

Compliance with state and federal ER laws can be a nuanced endeavor.  Differences exist between states in terms of the types of entities eligible to be certified to perform ER, clinical review criteria, whether oversight by a medical director is required, and timeframes for both standard and expedited appeals.  While complex, these regulations play an important part in consumer protection, ensuring appropriate care is provided for patients, and oversight of health plans.

This RegQuest module summarizes the key state and federal ER regulatory requirements, with convenient hyperlinks to informative sites and documents. The ER Module covers key component, including: information on the scope, regulatory contact information, licensure requirements, program requirements, reviewer qualifications, timelines for standard, expedited and experimental appeals, and other relevant information.

For more information regarding the External Review Module, please contact Garry Carneal, JD at Schooner Strategies at