In a new technical release, the government agencies responsible for implementing various health care reform requirements (the U.S. Departments of Labor, the Treasury, and Health and Human Services) have extended the reprieve that they previously granted with respect to certain rules affecting health benefit claims and appeals. Last year, these agencies announced that they would not enforce the following requirements until July 1, 2011:

  • Notifying a claimant of an urgent claim decision within a maximum of 24 hours (shortened from a 72-hour standard) 
  • Writing claim and appeal determination notices in a culturally and linguistically appropriate manner 
  • Preparing claim and appeal determinations to provide specified information, including diagnosis, treatment and denial codes and their meanings, and contact information for an applicable office of health insurance consumer assistance or ombudsman (the new technical release provides current contact information for these offices) 
  • Meeting a standard of strict compliance with the claim and appeal standards

(Click here to read an earlier legal alert that addresses the initial reprieve.)

The new technical release extends the non-enforcement period to January 1, 2012, for all of these requirements but one. Enforcement of the requirement to include specified information in notices will begin on a date that depends on the applicable plan year and, in part, on the information. However, for calendar-year plans, the extension for all information will last until January 1, 2012.

The extension allows additional time for the government agencies to issue further guidance on the new claim and appeal requirements before plans need to make adjustments. The technical release does not alter the complete exemption from the new claim and appeal requirements that applies to grandfathered plans.

If you have questions regarding the contents of this alert, please contact Edward I. Leeds at 215.864.8419 or leeds@ballardspahr.com.

As the federal health care reform effort gained steam, Ballard Spahr attorneys formed an initiative to monitor and analyze legislative developments. With federal health care reform now a reality, our attorneys are assisting employers in understanding the relevant changes and planning for the future. For more information on the firm’s Health Care Reform Initiative, please click here.


Copyright © 2011 by Ballard Spahr LLP.
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This alert is a periodic publication of Ballard Spahr LLP and is intended to notify recipients of new developments in the law. It should not be construed as legal advice or legal opinion on any specific facts or circumstances. The contents are intended for general informational purposes only, and you are urged to consult your own attorney concerning your situation and specific legal questions you have.