Health Care Reform's interim claims appeals regulations amended

The IRS issued amendments to the interim final regulations regarding internal claims and appeals and external review processes for group health plans and insurers.  Recall that the government had previously extended the non-enforcement period as noted in our ErisaALERT Health Care Reform Update Part III.  The term group health plans includes both insured and self-insured group health plans and does not apply to grandfathered plans.  Here are the highlights:

·         The time frame for deciding urgent care claims is back to 72 hours with the proviso that    urgent care claims be decided as quickly as possible but in no event later than 72 hours

·         The requirement for including diagnosis and treatment codes in notices of adverse benefit determination has been removed and a requirement to provide this information upon request has been added.

·         The threshold for providing denial notices in non-English language has been changed to 10% or more of the population residing in the claimant’s county.  The government will update data on its website periodically regarding this information.  If the threshold is met, the notice must include a one sentence statement in the relevant non-English language about the availability of language services. In addition to the one sentence requirement, the plan or insurance company must provide a customer assistance process with oral language services in the non-English language and provide written notices in the non-English language upon request.

·         The transition period for states to implement external review processes has been extended to December 31, 2011.

·         The scope of claims for which external review has not been initiated before September 20, 2011 is narrowed to claims that involve medical judgment or a rescission of coverage.

·         A plan may not delay payment because the plan disagrees and intends to seek judicial review.

The amendments, revised notices and other information can be found on EBSA’s website