So, it’s time for plans to update (or create) their EOB checklist and make sure that denial notices include all the necessary information.
Requirements from Original DOL Claims Procedures
(currently in effect)
- Specific reason for adverse determination (initial claim and appeal);
- Reference to specific plan provision on which determination based (initial claim and appeal);
- Description of any additional material or information necessary to perfect claim and explanation why material is necessary (initial claim only);
- Description of review procedures and time limits, including, if urgent claim, description of expedited review process (initial claim only);
- Statement of claimant’s right to bring civil action under ERISA § 502(a) following adverse determination on review (initial claim and appeal);
- Any specific internal rule, guideline, protocol, or similar criterion relied upon in making adverse determination, or statement that rule was relied upon and copy is available free of charge upon request (initial claim and appeal);
- If based on medical necessity or experimental treatment limit or exclusion, explanation of scientific or clinical judgment for determination applying plan terms to claimant’s medical circumstances, or statement that such explanation will be provided free of charge upon request (initial claim and appeal);
- Statement claimant entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to claim (appeal only);
- Statement describing any voluntary appeal procedures offered by plan and claimant’s right to obtain information about procedures (appeal only);
- The following statement: “You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local US Department of Labor Office and your State insurance regulatory agency.” (This requirement applies to appeal only, but DOL has indicated in Q&A guidance it will not enforce.)
New Content Required by PPACA Appeals Regulations
(applies to both claims and appeals for plan years beginning on of after 7/1/11)
- Information sufficient to identify claim involved, including date of service, health care provider, and claim amount (if applicable);
- Denial code and corresponding meaning;
- Statement describing availability, upon request, of diagnosis code and its corresponding meaning and treatment code and its corresponding meaning (applies to plan years beginning on or after 1/1/12);
- Description of plan or issuer's standard, if any, used in denying claim (final internal appeal notice also must include discussion of decision);
- Description of available internal appeals and external review processes, including information about how to initiate an appeal;
- Availability of, an contact information for, any applicable office of health insurance consumer assistance or ombudsman established under PPACA to assist individuals with internal claims and appeals and external review processes (list available at http://www.dol.gov/ebsa/capupdatelist.doc);
- If EOB is sent to an address in a county listed in the US Census Bureau chart adopted in regulations as reflecting counties where 10% or more of the population is literate only in the same non-English language, must include one-sentence statement about how to obtain notice or language assistance in that service (languages are Spanish, Mandarin, Navajo, and Tagalog). List can be found at 76 Fed. Reg. 37221 (June 24, 2011). Translations of the required sentence in the four languages can be found at www.dol.gov/ebsa/ (see model notices).
Note that DOL has issued model notices for both the internal claim denial notice and appeal denial notice, which can be found at http://www.dol.gov/ebsa/healthreform/.
Got a health-care reform question? You can ask YOUR health-care reform legislation question online at http://www.surveymonkey.com/s/second_opinions
You can find a handy list of Key Provisions of the Patient Protection and Affordable Care Act and their effective dates at http://www.groom.com/HCR-Chart.html
Christy Tinnes is a Principal in the Health & Welfare Group of Groom Law Group in Washington, D.C. She is involved in all aspects of health and welfare plans, including ERISA, HIPAA portability, HIPAA privacy, COBRA, and Medicare. She represents employers designing health plans as well as insurers designing new products. Most recently, she has been extensively involved in the insurance market reform and employer mandate provisions of the health-care reform legislation.
Brigen Winters is a Principal at Groom Law Group, Chartered, where he co-chairs the firm's Policy and Legislation group. He counsels plan sponsors, insurers, and other financial institutions regarding health and welfare, executive compensation, and tax-qualified arrangements, and advises clients on legislative and regulatory matters, with a particular focus on the recently enacted health-reform legislation.
PLEASE NOTE: This feature is intended to provide general information only, does not constitute legal advice, and cannot be used or substituted for legal or tax advice.