42 U.S.C. § 300gg: Appeals process

have in effect an internal claims appeal process; provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 300gg–93 of this title to assist such enrollees with the appeals processes; and allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process. a group health plan and a health insurance issuer offering group health coverage shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503–1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70256), and shall update such process in accordance with any standards established by the Secretary of Labor for such plans and issuers; and a health insurance issuer offering individual health coverage, and any other issuer not subject to subparagraph (A), shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures set forth under applicable law (as in existence on March 23, 2010 ), and shall update such process in accordance with any standards established by the Secretary of Health and Human Services for such issuers. shall comply with the applicable State external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans; or if the applicable State has not established an external review process that meets the requirements of paragraph (1); or if the plan is a self-insured plan that is not subject to State insurance regulation (including a State law that establishes an external review process described in paragraph (1)). The Secretary may deem the external review process of a group health plan or health insurance issuer, in operation as of March 23, 2010 , to be in compliance with the applicable process established under subsection (b), as determined appropriate by the Secretary. In applying the provisions of section 2719(b) of the Public Health Service Act ( 42 U.S.C. 300gg–19(b) ) to group health plans and health insurance issuers offering group or individual health insurance coverage, the Secretary of Health and Human Services, Secretary of Labor, and Secretary of the Treasury, shall require, beginning not later than January 1, 2022 , the external review process described in paragraph (1) of such section to apply with respect to any adverse determination by such a plan or issuer under section 2799A–1 or 2799A–2 [probably means section 2799A–1 or 2799A–2 of the Public Health Service Act, 42 U.S.C. 300gg–111 , 300gg–112], section 716 or 717 of the Employee Retirement Income Security Act of 1974 [ 29 U.S.C. 1185e , 1185f], or section 9816 or 9817 of the Internal Revenue Code of 1986 [ 26 U.S.C. 9816 , 9817], including with respect to whether an item or service that is the subject to such a determination is an item or service to which such respective section applies. The terms ‘group health plan’; ‘health insurance issuer’; ‘group health insurance coverage’, and ‘individual health insurance coverage’ have the meanings given such terms in section 2791 of the Public Health Service Act ( 42 U.S.C. 300gg–91 ), section 733 of the Employee Retirement Income Security Act ( 29 U.S.C. 1191b ), and section 9832 of the Internal Revenue Code [ 26 U.S.C. 9832 ], as applicable.”