When Do PPACA Claims & Appeals Rules Apply?

April 19, 2011 (PLANSPONSOR.com) - The effective dates for the new claims and appeals requirements under PPACA have changed more than once (even since we've written about this issue before).   

Not surprisingly, we have been receiving a number of questions asking us to clarify these various dates.

The Department of Labor issued a grace period – does the grace period apply to all of the new claims and appeals requirements?

No – the grace period (issued as part of Technical Release 2010-2) only applied to some of the requirements.  And in fact, the grace period itself has now been extended, but with different dates for different provisions.  Generally, all the new requirements were supposed to be applicable for plan years starting on or after 9/23/10.  The grace period extended some of these requirements to 7/1/11.  A new Technical Release (2011-01) has extended some of these dates further.   

Which requirements were applicable as of the original effective date (plan years beginning on or after 2/23/10)?

  • Appeals Procedures – Must provide new information considered on appeal to claimant and give opportunity to respond before final denial.
  • Conflict of Interest – Decisions regarding compensation and hiring of claims adjudicators cannot be based on likelihood they would deny claims.
  • Continued Coverage – Must continue to cover benefits during appeal process for concurrent care claims (same as current rule under DOL claims procedure regulations).
  • External Review – Must provide claimants with right to appeal internal review to independent review organization.

Which requirements haven been extended to plan years beginning on or after 1/1/12?

  • Urgent Care Claims – Initial claims must be determined within 24 hours.
  • Denial Notice Content – New content requirements, such as date of service, provider name, claim amount, denial code and meaning, standard for denying claims, description of external review, and contact information for health insurance consumer assistance.
  • Strict Adherence – Failure to strictly adhere to requirements (even if de minimis) may result in deemed exhaustion and loss of deference.
  • Foreign Language – Must provide notices in foreign language if certain thresholds met of claimants speaking same non-English language.

Which requirements have been extended to plan years beginning on or after 7/1/11?

  • Denial Notice Codes – Denial notice must include diagnosis code and meaning and treatment code and meaning.


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.