A Bit Of Relief For Claims Appeals Rules

Amid all the hoopla surrounding the six-month implementation date for health reform is some new (albeit quite technical) guidance that should help a bit with the new claims appeals rules.

In Technical Release No. 2010-2, the Department of Labor’s Employee Benefits Security Administration (EBSA) provides an enforcement grace period until July 1, 2011, for some of the new standards required under the Patient Protection and Affordable Act (ACA) for health care internal claims and appeals and external review. The enforcement grace period is in response to some group health plans and insurers’ requests for more time to change plan or policy procedures and to modify computer systems in order to comply with the new interim final claims regulations issued on July 23, 2010, and Aug. 23, 2010, to implement Public Health Service Act Sec. 2719 (click here for these and other ACA regulations).

PHSA Sec. 2719, as added by the ACA, requires that group health plans and health insurance issuers maintain an effective internal claims and appeals process and external review.

Specifically, during the grace period, the DOL and the IRS will not take any enforcement action against a group health plan, and HHS will not take any enforcement action against a self-funded nonfederal governmental health plan, that is working in good faith to implement the additional standards but that does not yet have them in place, with respect to the following standards:

• the timeframe for making urgent care claims decisions,


• providing notices in a culturally and linguistically appropriate manner,


• requiring broader content and specificity in notices, and


• substantial compliance failure and deeming the claimant to have exhausted the plan's or issuer's internal claims and appeals process.

HHS also is encouraging states to provide similar grace periods to insurers and assures states that they will not be cited for failure to substantially enforce these provisions.

Model Notice Revised

EBSA also has released a revised version of its “Model Notice of Adverse Benefit Determination.” In August, EBSA first released a set of model notices to satisfy the disclosure requirements of the interim final regulations, including the notice of adverse benefit determination and notices of a final internal adverse benefit determination and a final external review decision.

Claims regulations made changes to shorten the times for initial determinations with respect to urgent care claims, but did not make any changes to the times for making internal appeals decisions. The revised model notice makes clear that only the times for making the initial benefit determination were changed.

The revised notice of adverse benefit determination is here.