Wednesday, June 22, 2011

Appeal Regulations

As promised, the amendments to the earlier regulations about insurance appeals came out today. I must say that, although I am not thrilled, it's nowhere near as bad as I had feared. The following changes are significant, in my view:

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.
4. Content of notices -- Diagnosis and procedure codes are not included in notices and will not be provided unless requested, so you have to know to ask (and you now do).
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.
There are over 100 pages of rules here, so there may be a few that I haven't picked up on during my first read, but that's the basic gist. The changes are relatively technical, but they affect your rights. So if you have a question for me, ask in the comments and I'll either answer individually or blog on it. Thanks. Jennifer

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