On March 18, 2011, the Department of Labor (“DOL”) issued Technical Release 2011-01 (“TR 2011-01”), extending the enforcement grace period for four provisions of the interim final claims and appeals regulation. These provisions, which are applicable only to non grandfathered group health plans, (1) mandate faster responses to urgent care claims, (2) require notices to be provided in a non-English language in certain cases, (3) apply a new strict compliance standard, and (4) expand the required content for adverse benefit determinations. Prior to the issuance of TR 2011-01, these four provisions were scheduled to become enforceable July 1, 2011. Now, for calendar year plans, the provisions will not become enforceable until January 1, 2012. To take advantage of this extension, employers sponsoring non-grandfathered health plans should coordinate with their third party administrators and carriers and review the description of their claims procedures.
The Four Provisions
The four provisions at issue require non-grandfathered group health plans to:
- Notify a claimant of the grant or denial of an urgent care claim as soon as possible, but not more than 24 hours (rather than 72 hours) after receipt of a claim.
- Provide notices in a culturally and linguistically appropriate manner if a certain portion of plan participants are literate only in a non-English language.
- Strictly adhere to all requirements of the internal claims and appeals rules or have claims deemed exhausted—allowing the claimant to bypass all or part of the internal review process.
- Include additional content in notices of adverse benefit determinations. Specifically, notices must provide (1) the date of the service, (2) the health care provider, (3) any applicable claim amount, (4) the diagnostic, treatment, and denial codes, and the meaning of those codes, (5) a description of
any applicable standard, such as the standard for medical necessity, (6) a discussion of the final decision, (7) a description of the internal and external review procedures and how to initiate an appeal, and (8) contact information for any applicable office of health insurance consumer assistance or ombudsman.
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