OptumHealth has amended its stop loss contract to provide protection to self-insured plan sponsors who may face additional exposure resulting from changes in the claims appeal process under health reform.
The amendment, called an "extended liability endorsement," is included in all new and renewal OptumHealth stop loss contracts that take effect on or after Jan. 1, 2012, subject to state approval. OptumHealth has received approval in 20 states to date, with more state approvals expected to follow.
Beginning in 2012, PPACA allows individuals whose claim is denied by a health plan through its internal claims review process to appeal to an independent review organization (IRO). A claim that is initially denied may eventually have to be paid by the health plan if the IRO overturns the denial.
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