Short answer: Generally yes for non-grandfathered plans. A self-funded plan that is not subject to a state external review process must provide the federal external review process, which uses independent review organizations at no cost to the claimant.
Under the ACA claims rules, a plan not subject to an applicable state external review process must provide an effective federal external review process. Under the federal standards, the plan contracts with at least three independent review organizations (IROs) and rotates assignments among them or uses another unbiased method, the IRO cannot have financial incentives tied to upholding denials, and the claimant cannot be charged filing fees or other costs.
For expedited external review, the IRO contract must require notice of the decision as quickly as the claimant’s condition requires and no more than 72 hours after the IRO receives the request.
Most TPAs arrange the IRO contracts, but the employer should confirm that the plan document, SPD and service agreement provide for it, and that the stop-loss policy will honor an IRO decision that reverses a denial.