Sep 24, 2010

Update on Health Care Reform: Additional Guidance Released on Claims Appeals Process Changes

As mentioned in a previous SGR Client Alert, the Departments of Health and Human Services (“HHS”), Labor (“DOL”), and the Treasury (“IRS”) jointly-issued interim final rules and additional guidance on the claims appeals process changes under the Health Care Reform Legislation (the “Claims Appeals Process Changes”).

This week, the DOL released Technical Release 2010-02, providing group health plans and issuers an enforcement grace period to comply with certain requirements under the Claims Appeals Process Changes. Specifically, group health plans and issuers have until July 1, 2011 to implement the following standards:

  • The 24-hour timeframe for making urgent care claims decisions;
  • The requirement to provide notices in a culturally and linguistically appropriate manner;
  • The expanded content requirement for notices, including diagnosis, treatment and denial codes in any notice of adverse benefit determination; and
  • The deemed exhaustion of the plan’s internal claims and appeals process if a plan fails to adhere to the Claims Appeals Process Changes

provided that they are working in “good faith” to implement such standards.

As a reminder, the Claims Appeals Process Changes only apply to non-grandfathered health plans.

For more information on the Claims Appeals Process Changes under the Health Care Reform Legislation, please contact your SGR Executive Compensation and Employee Benefits counsel.


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