Is there a special claims procedure for urgent health care claims?
The PWBA has issued final regulations establishing new standards for processing claims under group health and disability benefit plans. These rules apply to all claims filed on or after January 1, 2002.
Short timeframe. Decisions on urgent health care claims must be made within 72 hours from the time the claim is made. There is also a 72-hour limit for decisions on appeals of denials of urgent care claims. Where non-urgent claims are involved, pre-service claims must be decided within a maximum of 15 days at the initial level, and 30 days on review of an adverse benefit determination. Decisions on post-service claims are subject to a maximum time period of 30 days for the initial decision and a maximum of 60 days on review of a denied claim.
Disability benefit claims. At the initial level, disability claims must be resolved within 45 days of receipt. A plan may extend the decision-making period for an additional 30 days for reasons beyond its control. If, after this first extension, the plan administrator determines that it will still be unable, again for reasons beyond its control, to make a decision, the plan may extend decision-making for a second 30-day period.
During this time the plan must keep the claimant informed about the issues that are delaying the decision and about any additional information the claimant should provide to the plan. Reviews of denials must be completed within 45 days, with an additional 45 days permitted.
New notice requirements. In situations involving pre-service claims, plans must provide a notice informing claimants that they failed to properly file a claim. This requirement will only be triggered by a communication from a claimant or a health care professional representing the claimant, and the notice may be provided orally unless requested in writing.
Claimants must be informed about the protocol that was used to deny the claim, providing a copy of it or telling about its availability. Also, notifications of claim denials based on medical necessity, experimental treatment or other similar exclusions or limits must either explain the scientific judgment of the plan or explain that a statement will be provide upon request.
Appeal of claim denials. Claimants are afforded 180 days in which to bring an appeal of a denied claim. Reviews are not conducted by a fiduciary who is a party or the one who made the initial adverse determination.