Friday, July 30, 2010

Agencies issue interim final regulations for internal appeal & external review of denied claims

On July 23rd, the Internal Revenue Service (IRS) and the Departments of Labor (DOL) and Health and Human Services (HHS) published interim final regulations regarding processes for internal claims and appeals, as well as external review processes, for insured and self-insured, non-grandfathered group health plans as required by the Patient Protection and Affordable Care Act (PPACA).

The regulations establish minimum standards for a new federal external review process that will be applicable to all ERISA-covered, self-insured group health plans. The rules also establish standards for a group health plan’s internal claim and appeal process, expand the types of decisions to which the appeal procedures apply and modify existing DOL claims procedure regulations.

For example, a response to an urgent care claim must now be made within 24 hours of receipt of the claim, instead of within 72 hours as permitted under the current DOL regulations on ERISA plan appeals.

We will provide further guidance and information on this provision once the proposed regulations are passed and as more comprehensive updates are available. For more information, click to access the Interim Final Regulations.

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