Affordable Care Act; Federal External Review Process; Request for Information, 70160-70162 [2010-28876]

Download as PDF 70160 Federal Register / Vol. 75, No. 221 / Wednesday, November 17, 2010 / Proposed Rules erowe on DSK5CLS3C1PROD with PROPOSALS-1 Department of Labor and the Department of Health and Human Services (the joint rulemaking). The text of those temporary regulations also serves as the text of these proposed regulations. The preamble to the temporary regulations explains the temporary regulations and these proposed regulations. Special Analyses It has been determined that this notice of proposed rulemaking is not a significant regulatory action as defined in Executive Order 12866. Therefore, a regulatory assessment is not required. It has also been determined that section 553(b) of the Administrative Procedure Act (5 U.S.C. chapter 5) does not apply to this proposed regulation. It is hereby certified that the collection of information contained in this notice of proposed rulemaking will not have a significant impact on a substantial number of small entities. Accordingly, a regulatory flexibility analysis is not required. The amendment to the temporary regulations adds a new third-party disclosure requirement so that it also applies to a group health plan that is changing health insurance coverage. The group health plan must provide to a succeeding or new health insurance issuer (and the succeeding or new health insurance issuer must require) documentation of plan terms (including benefits, cost sharing, employer contributions, and annual limits) under the prior health insurance coverage sufficient to make a determination whether a change described in § 54.9815–1251T(g)(1) has occurred. The hour and cost burden associated with this requirement is de minimis, because group health plans can satisfy the requirement by providing a copy of the policy or summary plan description to the succeeding or new health insurance issuer. This is not a significant burden for any plan and thus will not have a significant impact on a substantial number of small entities. For further information and for analyses relating to the joint rulemaking, see the preamble to the joint rulemaking. Pursuant to section 7805(f) of the Internal Revenue Code, this regulation has been submitted to the Chief Counsel for Advocacy of the Small Business Administration for comment on its impact on small business. Comments and Requests for a Public Hearing Before these proposed regulations are adopted as final regulations, consideration will be given to any VerDate Mar<15>2010 15:18 Nov 16, 2010 Jkt 223001 written comments (a signed original and eight (8) copies) or electronic comments that are submitted timely to the IRS. Comments are specifically requested on this amendment to the proposed regulations, including the prospective effective date of the rule and how that affects plans with different plan years. All comments will be available for public inspection and copying. A public hearing may be scheduled if requested in writing by a person that timely submits written comments. If a public hearing is scheduled, notice of the date, time, and place for the hearing will be published in the Federal Register. Drafting Information The principal author of these proposed regulations is Karen Levin, Office of the Division Counsel/Associate Chief Counsel (Tax Exempt and Government Entities), IRS. The proposed regulations, as well as the temporary regulations, have been developed in coordination with personnel from the U.S. Department of Labor and the U.S. Department of Health and Human Services. List of Subjects in 26 CFR Part 54 Excise taxes, Health care, Health insurance, Pensions, Reporting and recordkeeping requirements. Proposed Amendments to the Regulations Accordingly, 26 CFR part 54 is proposed to be amended as follows: PART 54—PENSION EXCISE TAXES Paragraph 1. The authority citation for part 54 continues to read in part as follows: Authority: 26 U.S.C. 7805 * * * Par. 2. Section 54.9815–1251 as published on June 17, 2010, at 75 FR 34571, is amended by revising paragraphs (a)(1), (a)(3)(ii), (f), and (g)(4) Example 9 to read as follows: § 54.9815–1251 Preservation of right to maintain existing coverage. (a) * * * (1) [The text of proposed § 54.9815–1251(a)(1) is the same as the text of § 54.9815–1251T(a)(1) published elsewhere in this issue of the Federal Register]. * * * * * (3) * * * (ii) [The text of proposed § 54.9815– 1251(a)(3)(ii) is the same as the text of § 54.9815–1251T(a)(3)(ii) published elsewhere in this issue of the Federal Register]. * * * * * (f) [The text of proposed § 54.9815– 1251(f) is the same as the text of PO 00000 Frm 00011 Fmt 4702 Sfmt 4702 § 54.9815–1251T(f) published elsewhere in this issue of the Federal Register]. (g) * * * (4) * * * Example 9. [The text of proposed § 54.9815–1251(g)(4) Example 9 is the same as the text of § 54.9815– 1251T(g)(4) Example 9 published elsewhere in this issue of the Federal Register]. Steven T. Miller, Deputy Commissioner for Services and Enforcement. [FR Doc. 2010–28866 Filed 11–15–10; 4:15 pm] BILLING CODE 4830–01–P DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Secretary 45 CFR Part 147 [Docket No. OCIIO–9986–NC] DEPARTMENT OF LABOR Employee Benefits Security Administration 29 CFR Part 2590 Affordable Care Act; Federal External Review Process; Request for Information Office of Consumer Information and Insurance Oversight, Department of Health and Human Services; Employee Benefits Security Administration, Department of Labor. ACTION: Notice; request for information. AGENCY: This notice is a request for information (RFI) to gain market analysis information in advance of one or more future Requests for Proposals (RFP). On July 23, 2010, the Departments of Health and Human Services, Labor, and the Treasury published interim final regulations regarding, among other things, procedures for external review of health plan denials. The regulations include a provision for a Federal external review process in instances where there is no applicable State process. This RFI solicits information that will enable the Departments of Health and Human Services (HHS) and Labor (DOL) to conduct a market analysis and assist the Departments in planning and developing the Federal external review process. HHS and/or DOL may contract for services required to fulfill the statutory and regulatory requirements of the Federal external review process established under section 2719 of the SUMMARY: E:\FR\FM\17NOP1.SGM 17NOP1 erowe on DSK5CLS3C1PROD with PROPOSALS-1 Federal Register / Vol. 75, No. 221 / Wednesday, November 17, 2010 / Proposed Rules Public Health Service Act, as amended by the Affordable Care Act, and its implementing regulations. DATES: Submit written or electronic comments by December 8, 2010. We note that responses to this notice are not offers and cannot be accepted by the Government to form a binding contract or issue a grant. The purpose of this RFI is to inform the RFP, not to gather public comments on the interim final rules for internal claims and appeals and external review processes under the Affordable Care Act; those comments are being collected and evaluated on a separate track. Information obtained as a result of this RFI may be used by the government for program planning and development on a non-attribution basis. Do not include any information that might be considered proprietary or confidential. ADDRESSES: In commenting, please refer to file code OCIIO–9986–NC. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission. You may submit comments in one of four ways (please choose only one of the ways listed): 1. Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the instructions under the ‘‘More Search Options’’ tab. 2. By regular mail. You may mail written comments to the following address ONLY: Office of Consumer Information and Insurance Oversight, Department of Health and Human Services, Attention: OCIIO–9986–NC, Room 445–G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201. Please allow sufficient time for mailed comments to be received before the close of the comment period. 3. By express or overnight mail. You may send written comments to the following address only: Office of Consumer Information and Insurance Oversight, Department of Health and Human Services, Attention: OCIIO–9986–NC, Room 445–G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201. 4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments before the close of the comment period to either of the following addresses: Office of Consumer Information and Insurance Oversight, Department of Health and Human Services, Attention: OCIIO–9986–NC, Room 445–G, Hubert H. Humphrey Building, 200 VerDate Mar<15>2010 15:18 Nov 16, 2010 Jkt 223001 Independence Avenue, SW., Washington, DC 20201. (Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal government identification, commenters are encouraged to leave their comments in the OCIIO drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.) Comments mailed to the address indicated as appropriate for hand or courier delivery may be delayed and received after the comment period. For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section. FOR FURTHER INFORMATION CONTACT: Linda G. Greenberg, Department of Health and Human Services, Office of Consumer Information and Insurance Oversight at (301) 492–4225 or Amy Turner, Department of Labor, Employee Benefits Security Administration at (202) 693–8335. SUPPLEMENTARY INFORMATION: Inspection of Public Comments. All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all electronic comments received before the close of the comment period on the following public Web site as soon as possible after they have been received at: http:// www.regulations.gov. Follow the search instructions on that Web site to view public comments. Comments received timely will be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at Room 445–G, Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, call 1–800–743–3951. I. Background Section 1001 of the Patient Protection and Affordable Care Act (the Affordable Care Act), Public Law 111–148, added a new section 2719 to the Public Health Service Act (the PHS Act). The Affordable Care Act also added a new section 715(a)(1) to the Employee Retirement Income Security Act (ERISA) and section 9815(a)(1) to the Internal Revenue Code (the Code) incorporating PO 00000 Frm 00012 Fmt 4702 Sfmt 4702 70161 the provisions of part A of title XXVII of the PHS Act (including PHS Act section 2719) into ERISA and the Code and making them applicable to group health plans and health insurance coverage in connection with group health plans. The Departments of Health and Human Services, Labor, and the Treasury (the Departments) published interim final regulations implementing the provisions of PHS Act section 2719 on July 23, 2010, at 75 FR 43330. Section 2719(b)(1) of the PHS Act and the Departments’ regulations provide that, if a State external review process that applies to and is binding on a health insurance issuer includes, at a minimum, the consumer protections set forth in the Uniform External Review Model Act issued by the National Association of Insurance Commissioners (‘‘NAIC Uniform Model Act’’), then the issuer is not required to comply with the Federal external review process. State law may provide similar protection for group health plans that are not subject to ERISA preemption, such as nonfederal governmental plans. The Departments, through guidance, are authorized to establish an external review process that is similar to a State external review process that meets the standards set forth in the interim final regulations for group health plans and health insurance coverage if a State has not established such a process.1 II. Questions This RFI requests comments on operational issues associated with implementation of a Federal external review process for health coverage in States that do not have an applicable external review process that meets the minimum Federal standards. HHS and DOL plan to ensure consistent and uniform processes for external review by independent review organizations (IROs) within relevant geographic areas and throughout the nation. The Department of HHS and/or Labor may enter into one or more contractual relationships to implement the external review process and reserve the right to award one contract or several contracts depending on the workload and decisions on how to divide the workload of the Federal external review process, as necessary. In particular, HHS and/or DOL may contract for services required to fulfill the statutory and regulatory 1 The Departments’ interim final regulations provide for a transition period for States until July 1, 2011 during which time HHS will work with States to assist them in making any necessary changes so that the State process provides, at a minimum, the consumer protections under the NAIC Uniform Model Act. E:\FR\FM\17NOP1.SGM 17NOP1 erowe on DSK5CLS3C1PROD with PROPOSALS-1 70162 Federal Register / Vol. 75, No. 221 / Wednesday, November 17, 2010 / Proposed Rules requirements of the Federal external review process established under section 2719 of the PHS Act and its implementing regulations. In such a case, the contractor would be responsible for conducting standard and expedited reviews of all adverse benefit determinations and final internal adverse benefit determinations that are eligible for external review as defined by the regulations. Reviews would be conducted in an accurate, efficient, timely, and consistent manner. In conjunction with completing these reviews, the contractor may be tasked with the following functions and responsibilities to support the permanent Federal external appeals process: • Development, maintenance, distribution, and update of ‘‘decision support’’ protocols; • Adjudication of external review cases, using established protocols; • Timely and accurate disposition of all external review cases; • Collection, consolidation, storage, maintenance, and transmission of information regarding the receipt and disposition of external review cases for the Federal external review process; • Performance of statistical and data analyses of external review cases to include trend analyses, and compliance with HHS data and reporting requirements including ad-hoc analyses for reports and inquiries from HHS, Congress, and other entities, and for purposes of continuous quality improvement; • Participation and coordination with other entities (including other IROs) involved in the Federal external review process for quality improvement purposes; • Communication of external review decisions to claimants and other parties involved in the case; • Case management and documentation, which may include document imaging to produce a complete electronic case file; and • Training all critical and qualified staff on all aspects of the external review process. Accordingly, the Departments of HHS and Labor are seeking to engage formally, in a transparent and participatory manner, with the public on best practices and standards currently used by IROs. Specific questions are set forth below. Comments are invited from all stakeholders on these issues. Qualified Organizations and Staff (1) What accreditation standards currently apply to IROs? VerDate Mar<15>2010 15:18 Nov 16, 2010 Jkt 223001 (2) What credentialing standards do IROs require for medical and legal reviewers? Is credentialing required or voluntary? (3) What procedures are currently used by IROs to assure that reviewers do not have conflicts of interest with disputing parties? (4) What are IROs’ current capacity for performing reviews? Does staffing and the time necessary for performing a review differ based on the type of claim (e.g., medical necessity, experimental/ investigational treatment, coverage issues, etc.)? Infrastructure (5) Please describe the type of data collection systems that IROs currently use to conduct analyses, reporting, and tracking of appeals and grievances. (6) Are the current data systems available in a secure, 508-compliant, web-based interactive structure? (7) What telecommunication systems and consumer technical support systems do IROs currently maintain for consumers (e.g., Web sites, 24-hour hotlines, helpdesk, and/or translation services for non-English speakers)? (8) What is a reasonable amount of time for a contractor to become fully operational (have all systems in place to conduct external reviews) after the date of a contract award? What resources would be necessary? (9) What considerations must be taken into account to smoothly transition from the current Federal interim external review process to a possible new permanent Federal external review process? (10) Do IROs currently operate nationally or in limited geographic areas? Would IROs that currently serve local areas be able to expand their service areas to possibly include other geographic areas such as other States? Are there any State and/or local licensing requirements? (11) Are there any special considerations HHS and/or DOL should be aware of in considering a specialized contract for urgent care appeals or for experimental and investigational treatments? Would such an approach have an impact on coordination? (12) Please describe the difference in standard operating procedures and resources (time, cost, personnel) for appeals that involve only medical necessity and those that involve both medical necessity and coverage questions. Data Collection (13) What data are currently collected by IROs for tracking appeals and conducting analyses? PO 00000 Frm 00013 Fmt 4702 Sfmt 4702 (14) What steps are taken to ensure confidentiality and security protections of patient information? Evaluation (15) Do IROs (or subcontractors) currently conduct evaluations of their operations? Do such evaluations include an assessment of how easy it is for consumers to access and use the external review process in a timely manner? Do evaluations result in quality improvement initiatives? If so, what are some examples of quality improvement initiatives undertaken by IROs? (16) What specific requirements should be applied to IROs to evaluate progress toward performance goals? What performance goals are the most appropriate? Signed at Washington, DC, November 10, 2010. Elizabeth Fowler, Director of Policy, Office of Consumer Information and Insurance Oversight. Department of Health and Human Services. Signed at Washington, DC, November 9, 2010. Phyllis C. Borzi, Assistant Secretary, Employee Benefits Security Administration Department of Labor. [FR Doc. 2010–28876 Filed 11–12–10; 11:15 am] BILLING CODE 4150–29– 4150–65–P DEPARTMENT OF VETERANS AFFAIRS 38 CFR Part 3 RIN 2900–AN83 Presumptive Service Connection for Diseases Associated With Persian Gulf War Service: Functional Gastrointestinal Disorders Department of Veterans Affairs. Proposed rule. AGENCY: ACTION: The Department of Veterans Affairs (VA) is amending its adjudication regulations concerning presumptive service connection for medically unexplained chronic multisymptom illnesses associated with service in the Southwest Asia theater of operations for which there is no record during service. This amendment is necessary to implement a decision of the Secretary of Veterans Affairs that there is a positive association between service in Southwest Asia during certain periods and the subsequent development of functional gastrointestinal disorders (FGIDs), and to clarify that FGIDs fall within the scope of the existing presumption of service connection for medically SUMMARY: E:\FR\FM\17NOP1.SGM 17NOP1

Agencies

[Federal Register Volume 75, Number 221 (Wednesday, November 17, 2010)]
[Proposed Rules]
[Pages 70160-70162]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2010-28876]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of the Secretary

45 CFR Part 147

[Docket No. OCIIO-9986-NC]

DEPARTMENT OF LABOR

Employee Benefits Security Administration

29 CFR Part 2590


Affordable Care Act; Federal External Review Process; Request for 
Information

AGENCY: Office of Consumer Information and Insurance Oversight, 
Department of Health and Human Services; Employee Benefits Security 
Administration, Department of Labor.

ACTION: Notice; request for information.

-----------------------------------------------------------------------

SUMMARY: This notice is a request for information (RFI) to gain market 
analysis information in advance of one or more future Requests for 
Proposals (RFP). On July 23, 2010, the Departments of Health and Human 
Services, Labor, and the Treasury published interim final regulations 
regarding, among other things, procedures for external review of health 
plan denials. The regulations include a provision for a Federal 
external review process in instances where there is no applicable State 
process. This RFI solicits information that will enable the Departments 
of Health and Human Services (HHS) and Labor (DOL) to conduct a market 
analysis and assist the Departments in planning and developing the 
Federal external review process. HHS and/or DOL may contract for 
services required to fulfill the statutory and regulatory requirements 
of the Federal external review process established under section 2719 
of the

[[Page 70161]]

Public Health Service Act, as amended by the Affordable Care Act, and 
its implementing regulations.

DATES: Submit written or electronic comments by December 8, 2010.
    We note that responses to this notice are not offers and cannot be 
accepted by the Government to form a binding contract or issue a grant. 
The purpose of this RFI is to inform the RFP, not to gather public 
comments on the interim final rules for internal claims and appeals and 
external review processes under the Affordable Care Act; those comments 
are being collected and evaluated on a separate track. Information 
obtained as a result of this RFI may be used by the government for 
program planning and development on a non-attribution basis. Do not 
include any information that might be considered proprietary or 
confidential.

ADDRESSES: In commenting, please refer to file code OCIIO-9986-NC. 
Because of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to http://www.regulations.gov. Follow the instructions under 
the ``More Search Options'' tab.
    2. By regular mail. You may mail written comments to the following 
address ONLY:
    Office of Consumer Information and Insurance Oversight, Department 
of Health and Human Services, Attention: OCIIO-9986-NC, Room 445-G, 
Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, 
DC 20201.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments to 
the following address only:
    Office of Consumer Information and Insurance Oversight, Department 
of Health and Human Services, Attention: OCIIO-9986-NC, Room 445-G, 
Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, 
DC 20201.
    4. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments before the close of the comment period 
to either of the following addresses:
    Office of Consumer Information and Insurance Oversight, Department 
of Health and Human Services, Attention: OCIIO-9986-NC, Room 445-G, 
Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, 
DC 20201.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal government 
identification, commenters are encouraged to leave their comments in 
the OCIIO drop slots located in the main lobby of the building. A 
stamp-in clock is available for persons wishing to retain a proof of 
filing by stamping in and retaining an extra copy of the comments being 
filed.)
    Comments mailed to the address indicated as appropriate for hand or 
courier delivery may be delayed and received after the comment period.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Linda G. Greenberg, Department of 
Health and Human Services, Office of Consumer Information and Insurance 
Oversight at (301) 492-4225 or Amy Turner, Department of Labor, 
Employee Benefits Security Administration at (202) 693-8335.

SUPPLEMENTARY INFORMATION: 
    Inspection of Public Comments. All comments received before the 
close of the comment period are available for viewing by the public, 
including any personally identifiable or confidential business 
information that is included in a comment. We post all electronic 
comments received before the close of the comment period on the 
following public Web site as soon as possible after they have been 
received at: http://www.regulations.gov. Follow the search instructions 
on that Web site to view public comments.
    Comments received timely will be available for public inspection as 
they are received, generally beginning approximately 3 weeks after 
publication of a document, at Room 445-G, Department of Health and 
Human Services, Hubert H. Humphrey Building, 200 Independence Avenue, 
SW., Washington, DC 20201, Monday through Friday of each week from 8:30 
a.m. to 4 p.m. To schedule an appointment to view public comments, call 
1-800-743-3951.

I. Background

    Section 1001 of the Patient Protection and Affordable Care Act (the 
Affordable Care Act), Public Law 111-148, added a new section 2719 to 
the Public Health Service Act (the PHS Act). The Affordable Care Act 
also added a new section 715(a)(1) to the Employee Retirement Income 
Security Act (ERISA) and section 9815(a)(1) to the Internal Revenue 
Code (the Code) incorporating the provisions of part A of title XXVII 
of the PHS Act (including PHS Act section 2719) into ERISA and the Code 
and making them applicable to group health plans and health insurance 
coverage in connection with group health plans. The Departments of 
Health and Human Services, Labor, and the Treasury (the Departments) 
published interim final regulations implementing the provisions of PHS 
Act section 2719 on July 23, 2010, at 75 FR 43330.
    Section 2719(b)(1) of the PHS Act and the Departments' regulations 
provide that, if a State external review process that applies to and is 
binding on a health insurance issuer includes, at a minimum, the 
consumer protections set forth in the Uniform External Review Model Act 
issued by the National Association of Insurance Commissioners (``NAIC 
Uniform Model Act''), then the issuer is not required to comply with 
the Federal external review process. State law may provide similar 
protection for group health plans that are not subject to ERISA 
preemption, such as nonfederal governmental plans. The Departments, 
through guidance, are authorized to establish an external review 
process that is similar to a State external review process that meets 
the standards set forth in the interim final regulations for group 
health plans and health insurance coverage if a State has not 
established such a process.\1\
---------------------------------------------------------------------------

    \1\ The Departments' interim final regulations provide for a 
transition period for States until July 1, 2011 during which time 
HHS will work with States to assist them in making any necessary 
changes so that the State process provides, at a minimum, the 
consumer protections under the NAIC Uniform Model Act.
---------------------------------------------------------------------------

II. Questions

    This RFI requests comments on operational issues associated with 
implementation of a Federal external review process for health coverage 
in States that do not have an applicable external review process that 
meets the minimum Federal standards. HHS and DOL plan to ensure 
consistent and uniform processes for external review by independent 
review organizations (IROs) within relevant geographic areas and 
throughout the nation. The Department of HHS and/or Labor may enter 
into one or more contractual relationships to implement the external 
review process and reserve the right to award one contract or several 
contracts depending on the workload and decisions on how to divide the 
workload of the Federal external review process, as necessary.
    In particular, HHS and/or DOL may contract for services required to 
fulfill the statutory and regulatory

[[Page 70162]]

requirements of the Federal external review process established under 
section 2719 of the PHS Act and its implementing regulations. In such a 
case, the contractor would be responsible for conducting standard and 
expedited reviews of all adverse benefit determinations and final 
internal adverse benefit determinations that are eligible for external 
review as defined by the regulations. Reviews would be conducted in an 
accurate, efficient, timely, and consistent manner. In conjunction with 
completing these reviews, the contractor may be tasked with the 
following functions and responsibilities to support the permanent 
Federal external appeals process:
     Development, maintenance, distribution, and update of 
``decision support'' protocols;
     Adjudication of external review cases, using established 
protocols;
     Timely and accurate disposition of all external review 
cases;
     Collection, consolidation, storage, maintenance, and 
transmission of information regarding the receipt and disposition of 
external review cases for the Federal external review process;
     Performance of statistical and data analyses of external 
review cases to include trend analyses, and compliance with HHS data 
and reporting requirements including ad-hoc analyses for reports and 
inquiries from HHS, Congress, and other entities, and for purposes of 
continuous quality improvement;
     Participation and coordination with other entities 
(including other IROs) involved in the Federal external review process 
for quality improvement purposes;
     Communication of external review decisions to claimants 
and other parties involved in the case;
     Case management and documentation, which may include 
document imaging to produce a complete electronic case file; and
     Training all critical and qualified staff on all aspects 
of the external review process.
    Accordingly, the Departments of HHS and Labor are seeking to engage 
formally, in a transparent and participatory manner, with the public on 
best practices and standards currently used by IROs. Specific questions 
are set forth below. Comments are invited from all stakeholders on 
these issues.

Qualified Organizations and Staff

    (1) What accreditation standards currently apply to IROs?
    (2) What credentialing standards do IROs require for medical and 
legal reviewers? Is credentialing required or voluntary?
    (3) What procedures are currently used by IROs to assure that 
reviewers do not have conflicts of interest with disputing parties?
    (4) What are IROs' current capacity for performing reviews? Does 
staffing and the time necessary for performing a review differ based on 
the type of claim (e.g., medical necessity, experimental/
investigational treatment, coverage issues, etc.)?

Infrastructure

    (5) Please describe the type of data collection systems that IROs 
currently use to conduct analyses, reporting, and tracking of appeals 
and grievances.
    (6) Are the current data systems available in a secure, 508-
compliant, web-based interactive structure?
    (7) What telecommunication systems and consumer technical support 
systems do IROs currently maintain for consumers (e.g., Web sites, 24-
hour hotlines, helpdesk, and/or translation services for non-English 
speakers)?
    (8) What is a reasonable amount of time for a contractor to become 
fully operational (have all systems in place to conduct external 
reviews) after the date of a contract award? What resources would be 
necessary?
    (9) What considerations must be taken into account to smoothly 
transition from the current Federal interim external review process to 
a possible new permanent Federal external review process?
    (10) Do IROs currently operate nationally or in limited geographic 
areas? Would IROs that currently serve local areas be able to expand 
their service areas to possibly include other geographic areas such as 
other States? Are there any State and/or local licensing requirements?
    (11) Are there any special considerations HHS and/or DOL should be 
aware of in considering a specialized contract for urgent care appeals 
or for experimental and investigational treatments? Would such an 
approach have an impact on coordination?
    (12) Please describe the difference in standard operating 
procedures and resources (time, cost, personnel) for appeals that 
involve only medical necessity and those that involve both medical 
necessity and coverage questions.

Data Collection

    (13) What data are currently collected by IROs for tracking appeals 
and conducting analyses?
    (14) What steps are taken to ensure confidentiality and security 
protections of patient information?

Evaluation

    (15) Do IROs (or subcontractors) currently conduct evaluations of 
their operations? Do such evaluations include an assessment of how easy 
it is for consumers to access and use the external review process in a 
timely manner? Do evaluations result in quality improvement 
initiatives? If so, what are some examples of quality improvement 
initiatives undertaken by IROs?
    (16) What specific requirements should be applied to IROs to 
evaluate progress toward performance goals? What performance goals are 
the most appropriate?

    Signed at Washington, DC, November 10, 2010.
Elizabeth Fowler,
Director of Policy, Office of Consumer Information and Insurance 
Oversight. Department of Health and Human Services.
    Signed at Washington, DC, November 9, 2010.
Phyllis C. Borzi,
Assistant Secretary, Employee Benefits Security Administration 
Department of Labor.
[FR Doc. 2010-28876 Filed 11-12-10; 11:15 am]
BILLING CODE 4150-29- 4150-65-P