News & Updates

Update: Effective September 15, 2011, the external review requirements for fully insured plans
(via the Massachusetts Office of Patient Protection) were changed.

Changes to Appeals Process and Claim Notices
An amended Interim Final Regulation and new guidance on appeals were issued on June 22, 2011. While the appeals regulation remains in a comment review period at this time, this summary includes some highlights.

Blue Cross Blue Shield of Massachusetts currently offers a comprehensive internal and external member appeals process, and when applicable, this process is explained in our member benefit materials.

Some requirements of this federal law did not require any change by us. However, certain changes did affect our appeals and claims process for both fully insured and self-insured health plans. Some changes became effective for plans on their anniversary dates, starting September 23, 2010. As a result of extensions granted by the federal government, some changes became effective on July 1, 2011, and others on January 1, 2012, as outlined below.¹ One set of changes, involving the state of Massachusetts' external review process, went into effect on September 15, 2011.

Changes Effective January 1, 2012
There were some changes to the requirements with the materials issued on June 22, 2011, as outlined below:

A statement on all adverse benefit determination notices that diagnosis and treatment codes and their descriptions are available at the member's request.²
A statement on all adverse benefit determination notices that language assistance service is available. We already offer language assistance services to our members and will continue to do so. Based on the new requirements, we will also provide written translations of these adverse benefit determination notices at the request of the member, in the four qualifying languages (Chinese, Spanish, Navajo, and Tagalog) deemed qualifying according to the requirements based on data published by the U.S. Census Bureau.
The current standard for responding within 72 hours to initial requests for prior authorization of coverage for urgent care situations will remain.³

Changes Effective September 15, 2011
The external review process for fully-insured (premium) plans saw some relatively minor changes. These changes are:

Giving insureds up to four months to file an external review request.
Giving insureds the option of filing a concurrent internal and external review for urgent expedited situations.
Revising timeframes for independent review organizations to issue determinations.

Changes Effective July 1, 2011
The following changes were implemented for adverse benefit determination notices. These notices include:

Information sufficient to identify the claim involved, including the date of the service, the health care provider, and the claim amount (if applicable).
The reason for an adverse benefit determination or final internal adverse benefit determination. It must include the denial code and its meaning and a description of the plan's standard (if any) that was used to deny the claim. For final internal adverse benefit determinations, this description must also include a discussion of the decision.
A description of available internal appeals and external review processes and how to initiate an appeal.
Contact information for the applicable office of health insurance consumer assistance or ombudsman established under PHS Act section 2793. Health Care for All is the organization currently designated in Massachusetts.

The following changes were made to our existing external review process for self-insured plans:

Appeals are eligible for adverse benefit determinations involving rescissions and medical judgment.
We have established contractual relationships with three independent review organizations (IROs). The vast majority of self-insured accounts use our internal and external appeals process, but a few either don't have an external review process or administer one on their own.

Changes Effective on Anniversary Dates on and After September 23, 2010
Providing continuation of coverage.

A continuation of coverage provision in certain instances, pending the outcome of the internal member appeal review, now applies to self-insured business. This practice has already been in place for our fully insured business.

Additional Information
The Department of Labor plans to issue final regulations in the near future, taking into account feedback received.

We will communicate more information as it becomes available. If you have questions, please contact your account executive.

1. Please note, this doesn't apply to standalone dental plans (e.g., Dental Blue^®) or standalone vision plans.

2. The diagnosis and treatment codes are typically submitted by the provider of service, such as doctor or other health care provider, so a claim for benefits can be processed.

3. Urgent care includes requests for benefits for ongoing or urgently needed treatment where following the standard review time period could seriously jeopardize the member's health.

This information is provided for informational purposes only and does not constitute legal advice. Please consult your legal counsel regarding your specific situation.

Please note that this content is only intended to describe national health care reform requirements under the Patient Protection and Affordable Care Act (PPACA). It does not address Massachusetts law requirements or the potential impact of Massachusetts law on federal PPACA requirements.

For purposes of PPACA implementation, Blue Cross Blue Shield of Massachusetts assumes the plan year is the policy year, unless an account notifies us otherwise.