New Appeals Processes and ERISA on EOBs

Transcription

1 For Distribution to Brokers/General Producers/Full-Service Producers Only July 13, 2011 New Appeals Processes and ERISA on EOBs MARKET: All Groups Background: The Patient Protection and Affordable Care Act (PPACA), also known as the federal health reform law, was enacted on March 23, 2010 with a variety of provisions to be implemented over the next 3 to 4 years. Current Situation: Regulations have been issued modifying the internal and external review rights of some members. These regulations extend Employee Retirement Income Security Act (ERISA) rights to a broader population, including direct bill and non-federal governmental entities, and require changes in the communication of internal and external review rights to members. Federal regulations, as well as state conforming regulations, also require changes to the language communicating those rights. Communications: Appeal and ERISA rights are initially communicated to the member on their Explanation of Benefits (EOB). EOBs produced on or after July 1, 2011 will include an insert which contains updated language explaining appeals and external review rights to members. We are in the process of finalizing EOB language that will be programmed into the system that produces the EOBs. Once this process is complete, the updated language will be displayed on the EOB and CareFirst will stop including inserts. For your reference, attached are the inserts that will be included in the EOBs. Members in grandfathered, self-insured groups may receive inserts that are not applicable to them. CareFirst is working to identify affected groups and suppress the insert in the EOBs to members in those groups. Additional information on health care reform and grandfathered groups can be found here. Should you have any questions, please contact your Broker Sales Representative. Shekar Subramaniam Associate Vice President, Broker Sales CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered trademarks of the Blue Cross and Blue Shield Association. CareFirst is a registered trademark of CareFirst of Maryland, Inc.

2 You are receiving this additional information as required by Federal, Maryland, Virginia, or District of Columbia law. This information applies to members who are residents of or are employed in a group based in Maryland, Virginia or Washington DC. If your receive coverage through your employer and the coverage is insured or if you have purchased an individual product, please follow the procedures listed in Paragraph A. If your group health plan coverage is self-insured, please follow the procedures listed in Paragraph B. Please check with your employer to see if your coverage is considered insured or self-insured. A. Insured Group Health Plan Coverage or Individual Product Coverage Maryland If you are dissatisfied with the outcome of the grievance, you, your authorized representative or your health care provider on your behalf may file a complaint with the Maryland Insurance Administration (MIA) within 4 months after receipt of the grievance decision. Additionally, you may file a complaint with the MIA if you, your authorized representative or your health care provider on your behalf do not receive a final grievance or appeal decision within 60 calendar days after the date on which the appeal of an adverse decision (which typically means a complete denial of a service for reasons not medically necessary, cosmetic or experimental/ investigative) or a coverage decision (a coverage decision is anything else denied or paid less than the full charge that is not an adverse decision) is filed. You may contact the MIA at the address and phone number on the main portion of your explanation of benefits. You may also have the right to have our decision reviewed by health care professionals who have no association with review to the Health, Education and Advocacy Unit at the following address: Health Education and Advocacy Unit Consumer Protection Division Office of the Attorney General 200 St. Paul Place, 16th Floor Baltimore, MD Phone: (410) or toll-free 1 (877) Fax: (410) Website: DC Members Please review your benefit booklet/health benefit contract to determine processes to follow for filing an appeal. You may have the right to have our decision reviewed by health care professionals who have no association with review to the DC Office of the Health Care Ombudsman at the following address: DC Office of the Health Care Ombudsman and Bill of Rights 899 North Capitol Street, NE, 6th Floor, Room 6037 Washington, DC Phone: (877) healthcareombudsman@dc.gov Virginia Members Please review your benefit booklet/health benefit contract to determine processes to follow for filing an appeal. You may have the right to have our decision reviewed by health care professionals who have no association with us, if our decision involved making judgments as to the medical necessity, medical appropriateness, health care setting, level of care or effectiveness of the health care service or treatment, by submitting a request for external review to the Virginia Bureau of Insurance at the following address: Virginia State Corporation Commission Life & Health Division, Bureau of Insurance P.O. Box 1157 Richmond, VA Phone: (877) Website: bureauofinsurance@scc.virginia.gov

3 If you are a member of a Virginia Managed Health Care Plan (an HMO or a plan that uses a network of providers) you may also contact: Office of the Managed Care Ombudsman Bureau of Insurance P.O. Box 1157 Richmond, VA Phone: (804) or toll-free: 1 (877) ombudsman@scc.virginia.gov Complaint Process Upon filing a complaint with the Maryland Insurance Administration or Maryland Office of the Attorney General or DC Office of the Health Care Ombudsman and Bill of Rights or Virginia State Corporation Commission Life & Health Division or Office of the Managed Care Ombudsman Virginia Bureau of Insurance if you are in a Virginia managed care plan, you, or your authorized representative, will be required to authorize the release of any of your medical records that will be required to be reviewed for the purpose of reaching a decision on the complaint. B. Self-Insured Group Health Plan Coverage If you receive your health care coverage through your employer and are in a non-grandfathered plan you may only have the right to request an external review through: Maryland: Health, Education and Advocacy Unit DC: DC Office of the Health Care Ombudsman and Bill of Rights Virginia: Virginia State Corporation Commission Life & Health Division, Bureau of Insurance at the addresses previously noted in this information. C. Maryland, Virginia and Washington DC Members If you are not sure what this explanation may mean please call the Member Service telephone number on your member ID card to request further clarification. You may also call Member Services if you have questions about how to file a grievance (an appeal) or if you would like to request copies of the relevant information regarding your claim, including copies of the benefit provision, guideline, protocol or other similar criterion on which this coverage determination was based, at no charge. Services denied as not medical necessary, cosmetic, experimental or investigational have been reviewed by a medical director. If, after you file a grievance, we continue to deny the payment or service, sustain the reduced coverage or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. D. Grandfathered Plans A grandfathered health plan can preserve certain basic health coverage that was already in effect when the Patient Protection and Affordable Care Act (the Act) was enacted. A grandfathered health plan means that a health benefit plan may not include certain consumer protections of the Act that apply to non-grandfathered plans (i.e. provision of preventive health services without any cost sharing). A grandfathered health plan must comply with certain other consumer protections such as the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to your group s human resources department. Grandfathered health plans are not required to abide by the internal and external appeal rights as defined by the Act. Non-grandfathered health care plans typically abide by all of the Act changes and consumer protections. E. ERISA For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1 (866) 444-EBSA (3272). Employee Retirement Security Act (ERISA). If you are enrolled through a health benefit plan that is subject to ERISA, and receive an adverse benefit determination on your appeal(s), you may bring a civil action under Section 502(a) of ERISA. To determine whether ERISA applies to your health benefit plan, please contact your Employer, Group Administrator, Plan Sponsor, or your Health Insurance Issuer if you are enrolled in a consumer direct plan. CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc. STF3323-V5 (7/11)

4 You are receiving this additional information as required by Federal and Maryland law. If you are not sure what this denial may mean, please call the Member Service telephone number on your member ID card to request further clarification. You may also call Member Services if you have questions about how to file a grievance (an appeal), or if you would like to request copies of the relevant information regarding your claim, including copies of the benefit provision, guideline, protocol or other similar criterion on which this coverage determination was based, at no charge. Services denied as not medical necessary, cosmetic, experimental or investigational have been reviewed by a medical director. If, after you file a grievance, we continue to deny the payment or service, sustain the reduced coverage or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. If your receive coverage through your employer and the coverage is insured or if you have purchased an individual product, please follow the procedures listed in Paragraph A. If your group health plan coverage is self-insured, please follow the procedures listed in Paragraph B. Please check with your employer to see if your coverage is considered insured or self-insured. A. Insured Group Health Plan Coverage or Individual Product Coverage If you are dissatisfied with the outcome of the grievance, you, your authorized representative or your health care provider on your behalf may file a complaint with the Maryland Insurance Administration (MIA) within 4 months after receipt of the grievance decision. Additionally, you may file a complaint with the MIA if you, your authorized representative or your health care provider on your behalf do not receive a final grievance or appeal decision within 60 calendar days after the date on which the appeal of an adverse decision (which typically means a complete denial of a service for reasons not medically necessary, cosmetic or experimental/investigative) or a coverage decision (a coverage decision is anything else denied or paid less than the full charge that is not an adverse decision) is filed. You may contact the MIA at the address and phone number on the main portion of your explanation of benefits. You may also have the right to have our decision reviewed by health care professionals who have no association with review to the Health, Education and Advocacy Unit at the following address: Health Education and Advocacy Unit Consumer Protection Division Office of the Attorney General 200 St. Paul Place, 16th Floor Baltimore, MD Phone: (410) or toll-free 1 (877) Fax: (410) Website: HEAU.htm CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. and is an independent licensee of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc. STF3322-v2 (6/11)

5 Upon filing a complaint with the MIA or Maryland Office of the Attorney General you, or your authorized representative, will be required to authorize the release of any of your medical records that will be required to be reviewed for the purpose of reaching a decision on the complaint. B. Self-Insured Group Health Plan Coverage If you receive your health care coverage through your employer, you may only have the right to request an external review through the Health, Education and Advocacy Unit. See the address previously noted in this information. ERISA Information For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1 (866) 444-EBSA (3272). Employee Retirement Security Act (ERISA). If you are enrolled through a health benefit plan that is subject to ERISA, and receive an adverse benefit determination on your appeal(st), you may bring a civil action under Section 502(a) of ERISA. To determine whether ERISA applies to your health benefit plan, please contact your Employer, Group Administrator, Plan Sponsor, or your Health Insurance Issuer if you are enrolled in a consumer direct plan. If you are enrolled through a selfinsured group health plan, please check with your employer to determine if your plan is considered grandfathered for the purposes of required changes to your right of review, including the right for an external review, that have been made as the result of Federal legislation.

6 You are receiving this additional information as required by Federal, Maryland, Virginia, or District of Columbia law. This information applies to members who are residents of or are employed in a group based in Maryland, Virginia or Washington DC. Maryland, Virginia and Washington DC Members If you are not sure what this denial may mean please call the Member Service telephone number on your member ID card to request further clarification. You may also call Member Services if you have questions about how to file a grievance (an appeal) or if you would like to request copies of the relevant information regarding your claim, including copies of the benefit provision, guideline, protocol or other similar criterion on which this coverage determination was based, at no charge. Services denied as not medical necessary, cosmetic, experimental or investigational have been reviewed by a medical director. If, after you file a grievance, we continue to deny the payment or service, sustain the reduced coverage or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. If your receive coverage through your employer and the coverage is insured or if you have purchased an individual product, please follow the procedures listed in Paragraph A. If your group health plan coverage is self-insured, please follow the procedures listed in Paragraph B. Please check with your employer to see if your coverage is considered insured or self-insured. A. Insured Group Health Plan Coverage or Individual Product Coverage Maryland If you are dissatisfied with the outcome of the grievance, you, your authorized representative or your health care provider on your behalf may file a complaint with the Maryland Insurance Administration (MIA) within 4 months after receipt of the grievance decision. Additionally, you may file a complaint with the MIA if you, your authorized representative or your health care provider on your behalf do not receive a final grievance or appeal decision within 60 calendar days after the date on which the appeal of an adverse decision (which typically means a complete denial of a service for reasons not medically necessary, cosmetic or experimental/investigative) or a coverage decision (a coverage decision is anything else denied or paid less than the full charge that is not an adverse decision) is filed. You may contact the MIA at the address and phone number on the main portion of your explanation of benefits. You may also have the right to have our decision reviewed by health care professionals who have no association with review to the Health, Education and Advocacy Unit at the following address: Health Education and Advocacy Unit Consumer Protection Division Office of the Attorney General 200 St. Paul Place, 16th Floor Baltimore, MD Phone: (410) or toll-free 1 (877) Fax: (410) Website: Consumer/HEAU.htm CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc. STF3323-v2 (6/11)

7 DC Members Please review your benefit booklet/health benefit contract to determine processes to follow for filing an appeal. You may have the right to have our decision reviewed by health care professionals who have no association with review to the DC Office of the Health Care Ombudsman at the following address: DC Office of the Health Care Ombudsman and Bill of Rights 899 North Capitol Street, NE, 6th Floor, Room 6037 Washington, DC Phone: (877) Virginia Members Please review your benefit booklet/health benefit contract to determine processes to follow for filing an appeal. You may have the right to have our decision reviewed by health care professionals who have no association with us, if our decision involved making judgments as to the medical necessity, medical appropriateness, health care setting, level of care or effectiveness of the health care service or treatment, by submitting a request for external review to the Virginia Bureau of Insurance at the following address: Virginia State Corporation Commission Life & Health Division, Bureau of Insurance P.O. Box 1157 Richmond, VA Phone: (877) Website: bureauofinsurance@scc.virginia.gov If you are a member of a Virginia Managed Health Care Plan (an HMO or a plan that uses a network of providers) you may also contact: Office of the Managed Care Ombudsman Bureau of Insurance P.O. Box 1157 Richmond, VA Phone: (804) or toll-free: 1 (877) ombudsman@scc.virginia.gov Complaint Process Upon filing a complaint with the Maryland Insurance Administration or Maryland Office of the Attorney General or DC Office of the Health Care Ombudsman and Bill of Rights or Virginia State Corporation Commission Life & Health Division or Office of the Managed Care Ombudsman Virginia Bureau of Insurance if you are in a Virginia managed care plan, you, or your authorized representative, will be required to authorize the release of any of your medical records that will be required to be reviewed for the purpose of reaching a decision on the complaint. B. Self-Insured Group Health Plan Coverage If you receive your health care coverage through your employer and are in a non-grandfathered plan you may only have the right to request an external review through: Maryland: Health, Education and Advocacy Unit DC: DC Office of the Health Care Ombudsman and Bill of Rights Virginia: Virginia State Corporation Commission Life & Health Division, Bureau of Insurance at the addresses previously noted in this information. C. Grandfathered Plans A grandfathered health plan can preserve certain basic health coverage that was already in effect when the Patient Protection and Affordable Care Act (the Act) was enacted. A grandfathered health plan means that a health benefit plan may not include certain consumer protections of the Act that apply to non-grandfathered plans (i.e. provision of preventive health services without any cost sharing). A grandfathered health plan must comply with certain other consumer protections such as the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to your group s human resources department. Grandfathered health plans are not required to abide by the internal and external appeal rights as defined by the Act. Nongrandfathered health care plans typically abide by all of the Act changes and consumer protections.

8 D. State of Maryland Employees, Dependents and Retirees State of Maryland individuals (as noted above) may follow the directions in paragraph A on the front of the paper. Concerns relating to adverse and coverage decisions should be submitted to the following address: Maryland Insurance Administration Life and Health Unit (for coverage decisions) Appeals and Grievances (for adverse decisions) 200 St. Paul Place, Suite 2700 Baltimore, Maryland Phone (410) or toll-free 1 (800) Fax: (410) (for coverage decisions), (410) (for adverse decisions) Website: E. ERISA For questions about your rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1 (866) 444-EBSA (3272). Employee Retirement Security Act (ERISA). If you are enrolled through a health benefit plan that is subject to ERISA, and receive an adverse benefit determination on your appeal(s), you may bring a civil action under Section 502(a) of ERISA. To determine whether ERISA applies to your health benefit plan, please contact your Employer, Group Administrator, Plan Sponsor, or your Health Insurance Issuer if you are enrolled in a consumer direct plan.