ACA §2719 (PHSA §2719)
ACA §2719 guarantees every non-grandfathered group + individual health plan a standardised internal appeal AND an independent external review when internal appeal is upheld.
What ACA §2719 (PHSA §2719) does
ACA §2719 (codified at 42 U.S.C. §300gg-19) requires every non-grandfathered group health plan and individual health insurance issuer to operate an internal claims-and-appeals process AND offer an external review process meeting state or federal standards. The jointly-promulgated DOL/HHS/IRS rule (29 CFR §2590.715-2719 / 45 CFR §147.136 / 26 CFR §54.9815-2719) sets the minimum standards: full and fair internal review, 180 days for the claimant to file, 30 days (urgent: 72 hours) for the plan to decide, and a federally-compliant external review by an Independent Review Organization (IRO) whose decision is binding on the plan.
When to invoke it
Cite ACA §2719 when (a) the plan is non-grandfathered (most plans), (b) the appeal is being denied at internal level, or (c) the plan tried to skip the external-review step. Pair the citation with the specific shortcoming — e.g., 'The plan denied the internal appeal in 45 days without granting the urgent-care 72-hour expedited window required by 29 CFR §2590.715-2719(b)(2)(ii)(F).'
Key deadlines and thresholds
| Requirement | Deadline / threshold |
|---|---|
| Time to file internal appeal | 180 days from denial |
| Plan decision on pre-service appeal | 30 days |
| Plan decision on post-service appeal | 60 days |
| Plan decision on urgent care appeal | 72 hours |
| External review request | 4 months from final internal denial |
| External review decision | 45 days (urgent: 72 hours) |
Plans this applies to
- Non-grandfathered group health plans
- Non-grandfathered individual health insurance
- ACA Marketplace plans
Frequently asked questions
What does ACA §2719 (PHSA §2719) require?
ACA §2719 (codified at 42 U.S.C. §300gg-19) requires every non-grandfathered group health plan and individual health insurance issuer to operate an internal claims-and-appeals process AND offer an external review process meeting state or federal standards. The jointly-promulgated DOL/HHS/IRS rule (29 CFR §2590.715-2719 / 45 CFR §147.136 / 26 CFR §54.9815-2719) sets the minimum standards: full and fair internal review, 180 days for the claimant to file, 30 days (urgent: 72 hours) for the plan to decide, and a federally-compliant external review by an Independent Review Organization (IRO) whose decision is binding on the plan.
When do I cite ACA §2719 (PHSA §2719) in an appeal?
Cite ACA §2719 when (a) the plan is non-grandfathered (most plans), (b) the appeal is being denied at internal level, or (c) the plan tried to skip the external-review step. Pair the citation with the specific shortcoming — e.g., 'The plan denied the internal appeal in 45 days without granting the urgent-care 72-hour expedited window required by 29 CFR §2590.715-2719(b)(2)(ii)(F).'
What are the key deadlines under ACA §2719 (PHSA §2719)?
Time to file internal appeal: 180 days from denial. Plan decision on pre-service appeal: 30 days. Plan decision on post-service appeal: 60 days. Plan decision on urgent care appeal: 72 hours. External review request: 4 months from final internal denial. External review decision: 45 days (urgent: 72 hours)
Which plans does ACA §2719 (PHSA §2719) apply to?
Non-grandfathered group health plans; Non-grandfathered individual health insurance; ACA Marketplace plans.
Related
- CARC 50Common denial code where ACA §2719 (PHSA §2719) applies.
- CARC 55Common denial code where ACA §2719 (PHSA §2719) applies.
- CARC 96Common denial code where ACA §2719 (PHSA §2719) applies.
- CARC 197Common denial code where ACA §2719 (PHSA §2719) applies.
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Sources
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