NAIRO Provides Healthcare Consumers With a Roadmap to the External Review Process Available Within the Health Insurance Marketplace

NAIRO announces the release of a new Issue Brief that clarifies external review options for consumers’ general understanding.

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We are giving consumers practical information that is vital to the understanding of their rights and consumer protections related to adverse benefit determinations and external appeals in the health insurance industry -Gib Smith

Portland, OR (PRWEB) February 24, 2014

Intending to provide consumers with education about the government-backed Health Insurance Marketplace, the National Association of Independent Review Organizations (NAIRO) announces the release of a new Issue Brief that informs general consumers on their rights and rules of the various external appeals process available under Marketplace programs.

The Issue Brief, “A Consumer’s Guide to Navigating the External Review Options Under the New Health Insurance Marketplace,” gives consumers an in-depth introduction to the external appeals process; provides background information on the role of independent review organizations (IROs); and covers the rules and regulations governing external appeals as they pertain to various insurance plans available within the federal and state insurance marketplaces.

“Consumers have a lot of questions about the Health Insurance Marketplace,” said Gib Smith, Executive Director of NAIRO. “With the release of this Issue Brief, we are giving consumers practical information that is vital to the understanding of their rights and consumer protections related to adverse benefit determinations and external appeals in the health insurance industry.”

External appeals are a fundamental consumer protection process, allowing consumers to pursue an independent, third-party review of a coverage decision in the event that their insurance provider decides to forego coverage of a specific healthcare service (such as an elective surgery or other treatment option).

The new Issue Brief is closely related to a recent Issue Brief published by NAIRO. That Issue Brief, titled “External Review Options Available Under the Federal Facilitated and State Marketplaces,” discusses the elements of federal external review options from a health plan’s perspective.

As background, when using Marketplace-related healthcare services, a consumer may have a claim denied, which means that a particular healthcare service is either not medically necessary or not covered by the consumer’s health insurance plan. At this point, the consumer has the option to file an appeal. After exhausting the health carrier’s internal appeals process, the appeal moves to external review. As required by law, external review is conducted by independent review organizations (IROs), which serve an essential function by guaranteeing expert, unbiased medical review of appealed claims.

With the Marketplaces expanding health coverage to millions of Americans, and offering an entirely new platform for providing and obtaining health insurance coverage, many questions about important regulations have gone unanswered. NAIRO’s Issue Brief seeks to answer the general consumer’s questions about external appeals in this new insurance environment.

Under the Affordable Care Act (ACA), certain health plans must use IROs that are accredited by URAC or a similar nationally-recognized accrediting organization to manage their respective ACA Federal External Review Processes. Within the healthcare industry, IRO accreditation is considered the gold standard for the companies providing external review services. Regardless of the venue, stakeholders within healthcare can utilize accredited IROs for internal and external appeals to ensure consistency, objectivity and accuracy when seeking medical review determinations.

The full Issue Brief is available here: http://www.nairo.org/news.php.

About NAIRO
NAIRO (The National Association of Independent Review Organizations) was formed by the majority of URAC-accredited IROs. The mission of NAIRO is to promote the quality and integrity of the independent review process at the internal and external levels. Utilizing the expertise of board-certified clinicians throughout the country, NAIRO members embrace an evidence-based approach to independent medical peer review, in order to help resolve coverage disputes between enrollees and their health plans. More information can be found at http://www.nairo.org.


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