Internal Claims and Appeals, External Review Requirements under PPACA

Transcription

1 Internal Claims and Appeals, External Review Requirements under PPACA COMPLIANCE CONSULTING SEPTEMBER 2015 ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 1 Agenda Who Must Comply Internal Claims and Appeals External Review Which? State External Review HHS Administered Federal Private Accredited IRO Federal Notice Requirements Action Steps 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 2 Arthur J. Gallagher & Co. 1

2 What Plans Must Comply Non Grandfathered Group Health Plans Both self insured and fully insured Plans subject to ERISA Non Federal Governmental Plans Church Plans Health Insurance Issuers (Group and Individual) 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 3 INTERNAL CLAIMS AND APPEALS PROCESS 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 4 Arthur J. Gallagher & Co. 2

3 Internal Claims and Appeals Department of Labor ( DOL ) claims procedure regulation now applicable to health insurance issuers and non ERISA plans PLUS six new or modified requirements PLUS continued coverage pending outcome of appeal 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 5 Internal Claims and Appeals DOL Claims Procedure Regulations Required to establish and maintain reasonable claims procedures that: Comply with requirements of the regulations Describe all claims procedures and applicable timeframes in summary plan description Do not inhibit of hamper the processing of claims Do not preclude an authorized representative from acting on behalf of a claimant Contain administrative processes and safeguards 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 6 Arthur J. Gallagher & Co. 3

4 Internal Claims and Appeals DOL Initial Claims Deadlines: Urgent care: as soon as possible taking into account medical exigencies, but no later than 72 hours after claim received. Concurrent care: Reduction/termination of approved ongoing course of treatment: sufficiently in advance to allow claimant to appeal. Request to extend treatment: within 24 hours (urgent) or regular timeframes for preservice or post service claims (non urgent). Pre Service: within a reasonable time (appropriate to medical circumstances), but no later than 15 days.* Post Service: within a reasonable time, but no later than 30 days.* * 15 day extension available (notice to claimant) DOL Appeals Deadlines: Urgent care: as soon as possible taking into account medical exigencies, but no later than 72 hours after appeal received. Concurrent care: within a reasonable time Pre Service: within a reasonable time (appropriate to medical circumstances), but no later than 30 days. Post Service: within a reasonable time, but no later than 60 days GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 7 Internal Claims and Appeals DOL Claims Procedures Regulations Appeals Time to file appeal: at least 180 days from receipt of adverse benefit determination Claimant may: Provide written comments, documents, or other information Request relevant documents from plan Review must provide no deference to initial determination, be conducted by an individual not involved in initial claim If medical judgment involved (in whole or part), reviewer must consult health care professional with appropriate experience 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 8 Arthur J. Gallagher & Co. 4

5 Internal Claims and Appeals DOL Claims Procedures Regulations Notices Reason(s) for denial and reference to relevant plan provision(s). Description of additional information necessary to perfect claim (and explanation). Description of appeals procedures and time limits. Statement of right to bring civil action under ERISA 502. If urgent care description of expedited appeals procedure. If internal rule, guideline, or protocol relied upon for decision, a copy must be available upon request. If based on medical necessity, experimental treatment, or similar exclusion, must include explanation of judgment (or statement that one is available upon request). Additional requirements for appeals denial notices: Statement of right to request relevant documents. Description of any voluntary appeal procedure GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 9 Internal Claims and Appeals PPACA s Six New or Modified Requirements 1) Adverse benefit determination broadened to include rescissions of coverage 2) Urgent care: As soon as possible, but in no event later than 72 hours Defer to attending provider as to whether claim is urgent care 3) Full and fair review requires the plan to provide any new or additional evidence in connection with the claim 4) No conflicts of interest 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 10 Arthur J. Gallagher & Co. 5

6 Internal Claims and Appeals 5) Notice Must be provided in a culturally and linguistically appropriate manner Additional content requirements: Information sufficient to identify the claim Ability to request diagnosis and treatment codes (and their meanings) Reason for adverse benefit decision and description of the standard used in denying claim Description of available internal appeal and external review processes Availability of (and contact information for) any applicable office of health insurance consumer assistance or ombudsman 6) Deemed exhaustion PLUS continued coverage pending outcome of appeal 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 11 EXTERNAL REVIEW PROCESS 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 12 Arthur J. Gallagher & Co. 6

7 External Review Comply with either: State external review process; or Federal external review process Applicable process depends on: Whether state law applies to and is binding on issuer (or plan) Whether plan is subject to ERISA Whether plan is insured or self insured Status of state law (if applicable) 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 13 External Review Issuers (insured plans): State external review process generally applies Status of State law (as determined by CMS/CCIIO): NAIC parallel process: meets all 16 minimum consumer protections (as of August 21, 2015 most States and Puerto Rico) NAIC similar process: standards similar to those outlined in regulations (as of August 21, States and D.C.) States not considered NAIC parallel or NAIC similar: Federal external review process (if plan chooses Federal process must notify HHS of choice) (as of August 21, states, 4 territories) List updated on CMS/CCIIO website 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 14 Arthur J. Gallagher & Co. 7

8 External Review Self insured plans: Federal external review process Self insured group health plans subject to ERISA: private accredited IRO process Self insured non federal governmental plans: plan chooses either HHS administered process or private accredited IRO process must notify HHS of choice Self insured church plans: private accredited IRO process Scope of Federal external review process 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 15 State External Review Insured plan in states with NAIC parallel process: follow State process Insured plan in states with NAIC similar process: follow State process (through December 31, 2015) NOTE: Starting January 1, 2016 State process will need to comply with minimum consumer protections in regulations 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 16 Arthur J. Gallagher & Co. 8

9 HHS-Administered Federal Administered by HHS agreement through the Office of Personnel Management/Federal contractor More information on process: and Initiatives/Consumer Support and Information/csg extappeals facts.html Self insured non federal governmental plan or issuer in States not considered NAIC parallel or NAIC similar must notify HHS (through HIOS) of choice 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 17 Private Accredited IRO Federal Details timelines for standard and expedited external review Standards for plan contracts with at least 3 independent review organizations (IROs) Notifications to claimant 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 18 Arthur J. Gallagher & Co. 9

10 NOTICE REQUIREMENTS 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 19 Notice Requirements Model Notices available: Notice of Adverse Benefit Determination Notice of Final Internal Adverse Benefit Determination Notice of Final External Review Decision Electronic disclosure: DOL safe harbor 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 20 Arthur J. Gallagher & Co. 10

11 Notice Requirements Culturally and Linguistically Appropriate Standards Applicable non English language: 10% or more of population in county is literate only in the same non English language. Currently: Spanish, Chinese, Navajo, Tagalog Requirements: Oral language services (telephone hotline) in non English language Provide notice in non English language upon request Include, in English versions of notices, a statement in applicable non English language indicating how to access language services (model language available) GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 21 ACTION STEPS 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 22 Arthur J. Gallagher & Co. 11

12 Action Steps Non Grandfathered Plans: Compliance check Notify HHS of choice of Federal external review process, provide updates as necessary (if applicable) Self insured non Federal governmental plans Plans in States not considered NAIC parallel or NAIC similar 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 23 Action Steps Grandfathered Plans: Consider how loss of grandfathered status may affect your plan Potential Future Changes in Guidance: State law changes Expiration of enforcement safe harbor Future regulatory or sub regulatory guidance 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 24 Arthur J. Gallagher & Co. 12

13 RESOURCES 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 25 Resources HHS State by State List of External Review Approvals: Model Notices: andappeals.html Culturally and Linguistically Appropriate Services (CLAS) County Data: Sheets and FAQs/Downloads/ CLAS County Data_ _clean_508.pdf 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 26 Arthur J. Gallagher & Co. 13

14 HRCI Approval Pending This program is being submitted for recertification credit through the HR Certification Institute. The approval process takes approximately 4 weeks. To obtain the program ID number for this program, which you can include on your recertification application form, please send an request to GBS.CEcredits@ajg.com. Under HRCI rules, only those individuals who attend the webinar and whose attendance we can verify will receive the program ID. Once your attendance has been verified and the program has been approved, you will receive an with the program ID number. As such, if a group attends the webinar, the program ID can only be given to the individual whose information was used to register GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 27 THANK YOU 2015 GALLAGHER BENEFIT SERVICES, INC. ARTHUR J. GALLAGHER & CO. BUSINESS WITHOUT BARRIERS 28 Arthur J. Gallagher & Co. 14