Such an appeal system must be expedient, particularly in situations that threaten the life or health of the patient, and conducted by appropriately credentialed individuals. If plans fail to meet designated time frames for reviewing appeals, patients must be able to appeal directly to an independent entity. Individuals must have access to an external, independent body with the capability and authority to resolve disputes for cases involving an experimental or investigational treatment, cases involving a denial of a service which was determined not to be medically necessary, or for cases where a patient s life or health is jeopardized. In the Patients Bill of Rights, States and the Department of Labor must establish an independent external appeals process for the plans under their respective jurisdictions. The plan must pay the costs of the process, and any decision is binding on the plan.
Consumers have the right to know all of their treatment options.
The Patients Bill of Rights prohibits plans from gagging doctors and from retaliating against providers who advocate on behalf of their patients. It protects providers in these situations from retribution, and protects providers who report quality problems to appropriate authorities from retribution. It also limits plans ability to provide incentives to providers to limit medically necessary services. Provider Due Process. Providers should receive reasonable notice of termination and should be allowed to review any information behind the termination decision and appeal such adverse determinations within the plan.