Health Care Reform established additional internal claims review procedures and created new external review and other rights for nongrandfathered health plans. The agencies originally issued interim final regulations regarding such claims review procedures in July 2010, which guidance has been recently amended in a number of respects, including:

  • Removal of the 24 hour decision-making deadline for pre-service urgent care claims and reverting back to the original 72 hour rule in the DOL claims procedures regulation.
  • No longer requiring that the diagnosis and treatment codes automatically be included as part of a notice of adverse benefit determination and, instead, simply inform claimants of the opportunity to request the diagnosis and treatment codes.
  • Creating an exception to the claimant’s ability to seek immediate external review or court action if the new internal procedures are not followed when the violation is de minimis, nonprejudicial, attributable to good cause or matters beyond the plan’s or issuer’s control, in the context of an ongoing good-faith exchange of information, and not reflective of a pattern or practice of noncompliance.
  • Modifying when and how plan communications must be provided in a different language in a culturally and linguistically appropriate manner.  

The amendments also included a number of other clarifications and transition rules. Employers should modify their non-grandfathered health plan documents (including a wrap welfare plan document and summary plan descriptions) and work with their insurance carriers or claims administrators to operationally comply with these expanded claims review procedures.