Plans and insurers will have an easier time complying with health reform’s internal appeals and external review rules, under rules issued today by the U.S. Departments of Labor, Treasury and Health and Human Services.
The changes, such as dropping the requirement for plans to display diagnosis and treatment codes on initial and final notifications of adverse determinations, should ease burdens for employer-sponsored plans. Another change lengthened the time allowed to review urgent care claims from “no more than 24 hours” to “as soon as possible but no more than 72 hours.”
The changes build on the original internal appeals and external review rules, which were issued on July 23, 2010. More details are available in Technical Release 2011-02, from the Department of Labor. Here is a bigger article on the topic, from the editors at Thompson Publishing.
According to the agencies, patients can still get federally mandated external review if an insurer cancels their coverage, and decisions by external review panels are still binding. The interim final rule will take effect on July 23, 2011. Comments from the public are being accepted until Aug. 23.
More flexible stance on codes
The agency dropped its demand that plans automatically provide diagnosis and treatment codes as part of a notice of adverse benefit determination (initial or final) and instead merely required that plans tell participants they are able to get them on request. Plans are still required to identify the claim, date of the service, health care provider and amount.
24-hour limit on urgent care claims eased
The July 2010 regulations provided that a plan or insurer must notify a claimant of a benefit determination (whether adverse or not) for urgent care claims no later than 24 hours after getting the claim. That represented a toughening of previous Labor Dept. rules, which required 72 hours for urgent care claims.
The agency now decided instead that plans can take 72 hours as per the DOL rules, but only as an outer limit, and only if the plan or insurer accepts the attending provider’s decision as to whether a claim constituted “urgent care.”
Minor errors will not invalidate internal review
Under the July 2010 rule, if a plan failed to give a fair or timely internal review of a claim, the participant would be considered to have exhausted the plan’s internal process and could immediately move on to seeking independent review or court remedies.
The newer rule creates an exception to this for compliance errors that are: (1) de minimis; (2) non-prejudicial; (3) attributable to good cause or matters beyond the plan or insurer’s control; (4) in the context of an ongoing good-faith exchange of information; and (5) not reflective of a pattern or practice of non-compliance.
External review temporarily narrowed
The regulators decided that the scope of claims eligible for federally mandated external review was too broad in the July 2010 appeal and review rules. The amendment narrowed the scope to only claims that involve (1) medical judgment as determined by the external reviewer; or (2) a rescission of coverage.
More businesses to furnish foreign-language notices
The agency increased the burden on all plans to furnish notices in foreign languages by lowering the thresholds set in July 2010. The new threshold is 10 percent of a county’s population being foreign language speaker (without English), and it requires all plans in such counties to print notices in the dominant foreign language.