Claims Appeals and External Review Process Amended

Issued July 21, 2011

Effective July 22, 2011, the U.S. Departments of Labor, Health and Human Services, and the Treasury have amended group health insurance plan regulations regarding claims appeals and the external review process.

Key Amendments Include:*

  • Urgent care claim determinations may take up to 72 hours (the original timeframe under the DOL claims regulation), rather than 24 hours.
  • Diagnosis and treatment codes are no longer required in claim denial notices.
  • Except for certain minor errors, if a health plan fails to "strictly adhere" to all of the requirements, the claimant is deemed to have exhausted the internal claims and appeals process and can proceed to external review or court.
  • The last day of the transition period for all health insurance issuers offering group and individual health insurance coverage is now December 31, 2011.

Covered employees must still appeal insurance claims through an internal review process. If a claim is denied, a claimant may be eligible for an independent external federal or state review.

*Amended regulations do not apply to grandfathered group health plans.

*Amended regulations do not apply to grandfathered group health plans.