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U.S. Department of Labor
Pension and Welfare Benefits Administration
November 20, 2000
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In the years since 1977, when the Department first adopted a benefit claims
regulation under ERISA, the health care industry has seen dramatic changes.
Those changes have shifted the usual method of delivery of health care from
doctors making independent medical decisions, while indemnity insurance
companies decide later whether to pay, to integrated delivery systems under
which managed care organizations review and oversee doctors’
medical decisions, often before care is provided.
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The patients’ rights claims procedure regulation, which is now being
issued in final form, creates new important patient protections that will
ensure that group health plan participants in today’s managed care
environment have access to a faster, fairer, fuller process for benefit
determinations.
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Faster decisions on initial claims - rather than 90 days (or more) under
current regulation, the new rule would require decisions (in most cases) not
later than:
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72 hours for urgent care claims
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15 days for pre-service claims
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30 days for post-service claims
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One 15 day extension for pre- and post-service claims
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Faster decisions on appeal of denied claims - rather than 60 days (or more)
under current regulation, the new rule would require decisions (in most
cases) not later than:
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72 hours for urgent care claims
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30 days for pre-service claims
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60 days for post-service claims
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Claimants have more time to file appeals - 180 days,
rather than current 60 days.
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If treating physician determines the claim is
“urgent,” plans must treat as urgent.
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Plans cannot impose fees or costs as a condition to
filing or appealing a claim.
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Arbitration permitted, but only with full disclosure
regarding the process, arbitrator, relationships, right to
representation, and only if claimant agrees after completing internal
appeal.
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Review must be de novo.
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Decision maker on appealed claims must be different
than the person deciding initial claim.
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Plans must consult with appropriate health care
professionals in deciding appealed claims involving medical judgment.
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Plans may not require more than two levels of review of
denied claims. If more than one level, both levels must be completed
within time frame applicable to one level.
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Special rules for the continuation or extension of
approved benefits or services to be provided over time (“concurrent
care decisions”). Individuals receiving approved care over a period of
time must have an opportunity for review before benefits are reduced or
terminated. Also, urgent care requests for an extension of approved
benefits must be decided within 24 hours.
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Plans must have procedures and safeguards for ensuring
and verifying consistent decision making.
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Plans must notify claimant of defective filing of claim
in case of pre-service claims.
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If plans fail to make timely decisions or otherwise
fail to comply with the regulation, claimants may go to court to enforce
their rights.
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Plans must provide participants a full description of
the plan’s claim procedures.
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Plans must provide specific reasons for denials,
including identification of and access to any guidelines, rules,
protocols relied upon in making the adverse determination.
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Plans must provide participants access to all
documents, records and other information relevant to the benefit
determination, without regard to whether the plan relied on the
material.
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Plans must disclose the name of medical professionals
consulted as part of the claims process.
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The final regulation updates and
clarifies certain summary plan description content requirements for
ERISA-covered employee benefit plans.
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The SPD content regulation implements
the information disclosure recommendations of the President’s Advisory
Commission by clarifying the information required to be disclosed to
plan participants and beneficiaries, in or as part of, the plan’s
summary plan description, and updates the disclosure rules applicable to
both pension and welfare benefit plans. The SPD content regulation:
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Provides that health plan SPDs
must describe:
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Any cost-sharing provisions,
including premiums, deductibles, coinsurance and copayment
amounts for which the participant or beneficiary will be
responsible
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Any annual or lifetime caps or
other limits on benefits under the plan
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The extent to which preventive
services are covered under the plan
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Whether, and under what
circumstances, existing and news drugs are covered under the
plan
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Whether, and under what
circumstances, coverage is provided for medical tests, devices
and procedures
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Provisions governing the use
of network providers, the composition of the provider network
and whether, and under what circumstances, coverage is provided
for out-of-network services
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Any conditions or limits
applicable to obtaining emergency medical care
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Any provisions requiring
preauthorization or utilization review as a condition to
obtaining a benefit or service under the plan.
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Requires that the SPDs of pension
and welfare benefit plan describe, among other things, the
procedures on qualified domestic relation orders (QDROs) and
qualified medical child support orders (QMCSCOs), the plan
sponsor’s authority to terminate the plan or eliminate benefits
under the plan, COBRA continuation rights, and updated information
on coverage by the Pension Benefit Guaranty Corporation and ERISA
rights.
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Repeals the limited exemption
relating to SPDs of health plans that provide benefits through
qualified health maintenance organizations (HMOs). Thus, health
plans that provide benefits through a federally qualified HMO must
comply with the improved SPD disclosure rule.
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Adopts in final form regulations
implementing amendments to ERISA made by the Newborns' and Mothers'
Health Protection Act. The final regulation requires health plan SPDs to
include information on requirements under federal or state law
applicable to the plan, and any health insurance coverage offered under
the plan, relating to hospital length of stay following newborn
deliveries.
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Rules
and Regulations for Administration and Enforcement; Claims Procedure; Final
Rule (11/21/00) |
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What you should know about filing your health benefits
claim
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