Tuesday, January 3, 2012

UHC explains impact of changes to internal appeals process for 2012

UnitedHealthcare (UHC) published the following information in their recent news alert regarding the impact of PPACA's required changes to internal appeals processes.

Changes to Internal Appeals Processes for 2012
Members of non-grandfathered health plans with effective dates on or after Sept. 23, 2010 (and grandfathered health plans that voluntarily adopted the appeals provisions of the Affordable Care Act), will see some additional information on their adverse benefit determinations (ABDs), including explanations of benefits (EOBs), beginning Jan. 1, 2012. Specifically, ABDs will contain the following additional information (if they did not already do so):
  • Language translation assistance in designated counties; and,
  • The availability, on request, of treatment and diagnosis code information.
Members should refer to their benefit plan documents, including amendments and notices, regarding the internal appeal and external review rights available under their plan.

The Departments of Health and Human Services, Labor and Treasury (the Agencies) issued interim final rules (IFR), and subsequent Technical Releases and an Amendment to the IFR that details the new requirements. As referenced above, here are the changes that will occur to ABDs beginning Jan. 1, 2012:

Language Translation Disclosure Requirements
There now is a single threshold with respect to whether members are informed of language assistance services to provide ABDs and other notices in a "culturally and linguistically appropriate" (CLA) manner. Instead of being based on the employer's eligible population (for group business) and county census data (for individual plans), the threshold for both is set at 10 percent or more of the population in the member's county, based on 2010 census data.

The Agencies have identified the states and counties that currently meet the 10 percent threshold in one or more of four languages: Spanish, Chinese, Tagalog and Navajo. Sample one-sentence statements in the relevant non-English language have been provided by the Agencies to be used for ABDs sent to a member residing in a threshold county beginning Jan. 1, 2012.

Member service centers will assist members in using oral translation services, and will provide written notices in the non-English language upon request.

Treatment and Diagnosis Codes
Health plans must also notify members of the opportunity to request diagnosis and treatment codes, and their meanings, in ABDs. This notice regarding diagnosis and treatment code information will begin appearing on Jan. 1, 2012. (Note: Some UnitedHealthcare systems were enhanced before the previous July 1, 2011 IFR deadline to include treatment and diagnosis codes in ABDs, and those systems will continue to display this information in ABDs).

The IFR Amendment clarifies that any request for diagnosis and treatment code information may not be (and is not) considered a request for an internal appeal or external review.

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