The guidance amended the internal claims and appeals requirements regarding: (1) urgent care claims, (2) adverse benefit determination notices, (3) culturally and linguistically appropriate notices, and (4) deemed exhaustion of internal claims and appeals. Under a March 2011 DOL technical release, the compliance deadline for PPACA's claims and appeals standards has been delayed until plan years beginning on or after January 1, 2012. The March 2011 release modified a September 2010 release by extending the compliance deadline from June 2011 to January 1, 2012 and by removing the requirement that plans make a good faith effort to implement the internal claims and appeals amendments during the grace period.

Under the new standards, plans must notify claimants of urgent care benefit determinations, regardless of whether they are adverse, as soon as possible (accounting for the medical exigencies), but no later than 72 hours after receiving the claim. Plans must defer to healthcare providers regarding whether the claims are for "urgent care." The latest guidance amends the July 2010 interim final regulation by lengthening the notice deadline from 24 hours to 72 hours and by adding the healthcare provider deference requirement.

The new standards require that plans state in notices of adverse benefit determination that diagnosis and treatment codes and their meanings are available upon request. The Departments released model notices with language plans may use to satisfy this requirement. The latest guidance also clarifies that requests for diagnosis and treatment codes do not alone trigger an internal appeal or external review. The guidance significantly relaxes the rules under the July 2010 interim final regulations, which required diagnosis and treatment codes and their meanings be provided automatically in adverse benefit determination notices.

Section 2719 of PPACA requires plans to provide notice of available internal and external appeal procedures to participants in a culturally and linguistically appropriate manner. The latest guidance limits such notice to participants in counties where 10% or more of the population is only literate in the same non-English language based on U.S. census data. A list of counties meeting this non-English threshold will be updated annually on the Departments' web sites. Currently, the non-English threshold is met in 255 counties. In New York, the threshold is met for Spanish in Bronx, New York, and Queens counties. If the non-English threshold is satisfied, every English notice a group health plan sends to participants in those counties must prominently display a one-sentence statement in the non-English language offering agency-provided language-assistance services. The Departments' model adverse benefit determination notices offer example sentences that satisfy this requirement in Spanish, Tagalog, Chinese, and Navajo. Plans must also provide written notices in the non-English language upon request, and must have a customer assistance process (e.g., a telephone hotline) providing language services in the non-English language to answer questions and assist with filing claims and appeals. The most significant amendment to the July 2010 interim final regulations was to standardize the percentage threshold for triggering the non-English notice requirements. The July 2010 rules had required each plan to individually test whether its participant pool met a certain non-English percentage threshold.

The latest guidance provides that internal claims and appeals procedures are deemed exhausted, and claimants may immediately seek de novo external review, if the plan fails to satisfy all of the internal claims and appeals process standards, except where the violation is (1) de minimis, (2) non-prejudicial, (3) attributable to good cause or beyond the plan's control, (4) in the context of an ongoing, good faith information exchange, and (5) not reflecting a pattern or practice of noncompliance. Claimants are entitled to an explanation from the plan addressing why it meets these requirements upon written request. The plan then has 10 days to provide the explanation. If the external reviewer or court rejects a request for immediate review because the plan satisfies these requirements, then the plan must provide claimants notice that they can re-file and pursue the internal appeal. Claimants have 10 days from receipt of the notice to re-file. The latest guidance drastically eases the burden of the July 2010 interim final regulations, which stated that claimants could seek de novo external review whenever the plan failed to "strictly adhere" to the internal claims and appeals rules, without exception. Read full article.