Changes to the Claims and Appeals Process
Please note: This is a summary only. For additional information, click here.
The Affordable Care Act creates new regulations aimed at protecting consumers through the claims and appeals process. Because SelectHealth maintains a robust, member-friendly appeals process, we are already in compliance with many of these provisions. However, there will be some changes to our existing processes.
These changes are effective for new and renewing plans on or after October 1, 2010. Given the complexity of the mandates, the Department of Labor has provided a non-enforcement period for many of these regulations, extending to January 1, 2012.
Changes in effect for new and renewing plans, as of October 1, 2010
- Rescission—Insurers cannot rescind a policy, except in cases of intentional misrepresentation of material fact or fraud. Additionally, insurers must provide members with 30-day notification before rescinding a policy, during which time the member may appeal the rescission.
- Full and fair review—Before a final internal adverse benefit determination is made, insurers must provide members with any new information relied upon as rationale for the denial. Insurers must also allow time for the review of that information.
- Denials of application for coverage—Consumers may appeal when an application for Individual plan coverage is denied.
- Appeals for Individual plan members—Individual plan members are only provided one level of internal appeal. Members on an employer-sponsored plan will continue to have up to three levels of internal appeal.
Changes in progress
- Foreign language—Notices such as an Explanation of Benefits or denial letter must be provided in the member’s native language, if the member is literate only in that language and certain population requirements are met.
- Denial notices—Notices must be enhanced to include information to identify the claim as well as the opportunity to request diagnosis and treatment codes (with their corresponding meanings), and reason for denial with a description of the standard used in denying the claim.
- External review—Plans or issuers must comply with either a state or federal external appeals process. Fully-insured groups will adhere to the state process determined by the Utah Insurance Department (UID). Self-insured plans will adhere to the federal external review process.
Grandfathered status
Because these regulations enhance the claims and appeals process for our members, SelectHealth has chosen to implement these changes for both grandfathered and non-grandfathered plans.
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