1. Federal external appeals -- for plans subject to federal external appeals, those appeals are limited to issues involving the exercise of medical judgment and rescissions (retroactive policy cancellations) -- NOT contractual or legal issues. That seems to exclude coding issues, whether prior authorization was required, and certainly contract interpretation questions.
2. The threshold for deciding when notices have to be translated is no longer 10% of employees at a firm who speak a language other than English; it's now 10% of people in a county. The upshot is that notices have to be in English and Spanish only except for 6 counties in the entire US, where there is more than 10% Chinese, Tagalog, or Navajo, and even then, people have to request the translation.
3. Urgent care claims are decided in 72 hours not 24.
5. The 16 minimum consumer protections with which state external appeal laws have to comply with are relaxed until 2014. The changes are as follows:
- Exhaustion is no longer unnecessary because the issuer/plan fails to comply with the rules except where the failures to comply are de minimis (minimal)
- The deadline for filing external appeals was 120 days, now 60 days
- The independent review organization was assigned randomly; now impartially
- No requirement that the claimant be allowed 5 days in which to submit additional information to the external reviewer.