Amendments to the PPACA Claims and Appeals Regulation, an ERIC FocusOn Conference Call

Conference Call

Joan A. Disler, Member of the Firm and Chair of the Employee Benefits practice, will moderate this conference call hosted by The ERISA Industry Committee. Panelists will review the changes to the PPACA claims and appeals regulations and Technical Release 2011-02.

Ms. Disler will be joined by Gretchen Harders, a Member of the Firm in the Employee Benefits practice, and Associates Adam Solander and Shawn Gilman of the Health Care and Life Sciences practice.

Recently, Treasury, Labor, and HHS published an amendment to the interim final claims and appeals regulation under PPACA that they issued last July. This new amendment made some significant changes to the original regulation, including revisions in the areas of:

  • notification of a benefit determination with respect to a pre-service claim involving urgent care;
  • provision of diagnosis and treatment codes in notices of adverse benefit determination;
  • the "strict adherence" standard for bypassing internal review;
  • application of the "culturally and linguistically appropriate" standard; and
  • the scope of claims eligible for external review.

At the same time, the Department of Labor published Technical Release 2011-02 to offer additional guidance on the federal and state external review processes.