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:
Changes Effective September 15, 2011
The external review process for fully-insured (premium) plans saw some relatively minor changes. These changes are:
Changes Effective July 1, 2011
The following changes were implemented for adverse benefit determination notices. These notices include:
The following changes were made to our existing external review process for self-insured plans:
Changes Effective on Anniversary Dates on and After September 23, 2010
Providing continuation of coverage.
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.