In what comes as welcome news to many employers, the Obama administration just eased some of the regs proposed last year involving internal healthcare claims and appeals processes.
The regulations, which were designed to protect patients who receive health insurance claims denials, were part of the healthcare reform law and only apply only to non-grandfathered health plans.
The amended regs were recently published in the Federal Register.
Urgent-care decisions
The biggest change involves the amount of time healthcare plan enrollees have to be notified of an urgent-care coverage decision (whether it’s a denial or not).
Originally, the regulations said enrollees would have to be notified by their employer or plan administrator of a coverage determination in urgent care situations within 24 hours — a reduction of the previous 72-hour limit.
The feds have changed their mind and now say they will allow plans to notify enrollees of such coverage decisions within 72 hours.
Diagnosis/treatment codes
The original regs also said when claims denial notices are issued, they must explain what treatments aren’t covered under the plan and why — complete with diagnostic codes used by doctors, hospitals and nurses.
Now, thanks to the recent amendments, diagnosis and treatment codes will no longer need to be included in a benefit denial. But they must be supplied upon request.
Notice language
Also amended requirement was the mandate that claims appeals and review notices be provided to non-English speaking participants in a “culturally and linguistically appropriate manner.”
Whether or not a plan had to provide notices in another language was dependent upon the amount of enrollees a plan had who were literate in the same non-English language.
For plans that cover more than 100 participants, if the plan had 500 participants — or at least 10% — that spoke the same non-English language, the plan would have to provide notices in that language.
The change: Now the requirement applies if at least 10% of the population in the county in which a participant resides speaks the same non-English language.
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