Agencies Clarify Requirements for Health Plan Claims Procedures


The Patient Protection and Affordable Care Act (PPACA) mandates certain requirements for claims and appeals procedures that must be followed by all health insurers and group health plans, including employer-provided plans that are subject to the Employee Retirement Income Security Act (ERISA). PPACA was originally enacted in 2010, and initially required compliance only with ERISA's claims and appeals rules. However, through prior guidance issued jointly by the Departments of Treasury, Labor and Health and Human Services (the Departments), the claims and appeals rules have been expanded. In guidance issued on June 22 (the Guidance), the Departments have clarified the new claims and appeals requirements.

Before PPACA, ERISA generally set forth claims and appeals procedures that included deadlines for responses to claims and appeals and mandated the inclusion of certain provisions in such responses. Pursuant to the previously issued guidance, the PPACA claims and appeals requirements (which will supersede ERISA's requirements) expand upon the pre-PPACA requirements. The new requirements include...

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