Legal Bulletins
New Health Plan Claims and Appeals Regulations: Common Plan Provisions That Will Have To Be Changed
New claims and appeals regulations issued by the U.S. Department of Labor will require significant changes by group health plans, and the new regulations apply to all claims that are filed on and after January 1, 2002.
IF YOUR PLAN NOW PROVIDES | IT MUST BE CHANGED TO PROVIDE |
|---|---|
Decisions on claims will be made within 90 days | Decisions on urgent pre-service claims will be made within 72 hours, decisions on non-urgent pre-service claims within 15 days, and decisions on post-service claims within 30 days |
Decisions on appeals will be made within 60 days | Decisions on urgent pre-service appeals will be made within 72 hours, decisions on non-urgent pre-service appeals within 30 days (15 days if two levels of appeal are required), decisions on post-service appeals within 60 days (30 days if two levels of appeal are required) |
The time to make a decision on a claim may be extended by 90 days | The time to make a decision on urgent pre-service claims cannot be extended; the time to make a decision on non-urgent pre-service claims and on post-service claims may be extended by 15 days |
The time to make a decision on an appeal may be extended by 60 days | The time to make a decision on an appeal may not be extended (except for multiemployer plans) |
Appeals must be filed within at least 60 days | Appeals must be filed within at least 180 days |
There are more than two required levels of appeal before a suit may be filed in court | No more than two levels of appeal may be required before a suit may be filed in court |
A claim or appeal denial will include specific reason(s) for the denial and references to specific plan provisions | A claim or appeal denial will also include any internal rule, guideline, or protocol that was relied upon, or a statement that it will be provided free of charge upon request; if the claim or appeal denial is based on medical necessity or experimental treatment or any similar exclusion, the denial will include an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request |
The new claims and appeals regulations require many more changes than those outlined here.
If you sponsor an insured plan, the insurer may make some or all of the required changes. Contact your insurer now and find out what changes the insurer will make, and what changes you will have to make. Then contact your employee benefits counsel to monitor your insurer and to make the changes for which you are responsible.
If you sponsor a self-funded plan that is administered by a third-party administrator, the administrator may make some or all of the required changes. Contact your third-party administrator now and find out what changes the administrator will make, and what changes you will have to make. Then contact your employee benefits counsel to monitor your third-party administrator and to make the changes for which you are responsible.
If you sponsor a self-funded plan that is administered in-house, contact your employee benefits counsel now to make the required changes.