March 22, 2011

HRB 31 - Delay in Claims and Appeals Enforcement

Released March 22, 2011I Download as a PDF

March 22, 2011 --  One of the provisions of the Patient Protection and Affordable Care Act (PPACA) is the expansion of the internal claims and appeal, and external review rules.  The PPACA not only augments the internal claims and appeals rules applicable to ERISA plans by adding an external review requirement, among other things, but it also extends these rules to plans exempt from ERISA, such as state and local government plans, and church plans.  These rules apply to non-grandfathered plans (those not in existence on 3/23/10), as well as to plans that lose grandfathered status.  

In September, 2010, the Agencies issued Technical Release No. 2010-02 that provided for a non-enforcement grace period until July 1, 2011 for certain claim and appeal standards (see Claims and Appeals: Clarifications and Revised Model Notice of Adverse Determination from the CBIZ Health Reform Bulletin, Agencies Issue PPACA Clarifications).  This Technical Release did not relieve the plan from complying with the rules; but rather relieved them of any enforcement for failure to comply with the specific technicalities of the above requirements. 

On March 18, 2011, the Department of Labor issued Technical Release No. 2011-01.  This guidance provides additional relief from certain provisions relating to claims and appeals, and the external review standards.  According to this guidance, generally, the rules will be enforced effective for plan years beginning on or after January 1, 2012.  The primary purpose for the delay is to give the government agencies (HHS, DOL, and IRS) time to issue further implementation guidance.  The specific parts of the rules included in the non-enforcement grace period include:

  1. Timeframe for making urgent care claim decisions;
  2. Providing notices in a culturally and linguistically appropriate manner;
  3. Substantial compliance with claims and appeals standards; and
  4. Disclosure of diagnosis and treatment codes, together with their corresponding meanings, to be included in detailed notifications of benefit determinations.

Different from the original guidance, this non-enforcement guidance will not obligate plans to make a good faith attempt to comply during the delay period.  

The enforcement grace period applicable to other disclosure standards is extended from July 1, 2011 until the first day of the first plan year beginning on or after July 1, 2011 (January 1, 2012 for calendar year plans).  These standards include:

  1. Disclosure of information sufficient to identify a claim (other than the diagnosis and treatment codes);
  2. Reasons for an adverse benefit determination;
  3. Description of available internal appeals and external review processes; and
  4. Contact information of any available office of health consumer or ombudsman assistance program.  To assist plan sponsors with this information, the Technical Release  includes a current list of States with Consumer Assistance Programs on pages 7-12. 

This non-enforcement delay is, again, an indication of the Administrative Agencies’ commitment to facilitate compliance with the law, as efficiently as possible.

Additional CBIZ Health Reform Bulletins on Claims and Appeals and External Review:




About the Author:  Karen R. McLeese is Vice President of Employee Benefit Regulatory Affairs for CBIZ Benefits & Insurance Services, Inc., a division of CBIZ, Inc.  She serves as in-house counsel, with particular emphasis on monitoring and interpreting state and federal employee benefits law.  Ms. McLeese is based in the CBIZ Leawood, Kansas office.




The information contained herein is not intended to be legal, accounting, or other professional advice, nor are these comments directed to specific situations. The information contained herein is provided as general guidance and may be affected by changes in law or regulation. This information is not intended to replace or substitute for accounting or other professional advice. You must consult your own attorney or tax advisor for assistance in specific situations. This information is provided as-is, with no warranties of any kind. CBIZ shall not be liable for any damages whatsoever in connection with its use and assumes no obligation to inform the reader of any changes in laws or other factors that could affect the information contained herein. As required by U.S. Treasury rules, we inform you that, unless expressly stated otherwise, any U.S. federal tax advice contained herein is not intended or written to be used, and cannot be used, by any person for the purpose of avoiding any penalties that may be imposed by the Internal Revenue Service.


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