On June 22, the DOL and Treasury (jointly) issued final rules on some of the claims appeal processes required in Health Care Reform:
Time Limit for Urgent Care Claim Decisions:
The 2010 IFR set a time limit of 24 hours for making decisions on urgent care claims.
Amended Rules: Health plans or insurers are required to provide notification of benefit determination for an
urgent care claim as soon as possible and no later than 72 hours after receiving the claim. The health plan or
insurer must defer to the attending healthcare provider’s determination that the claim involves
Diagnosis and Treatment Codes:
Health plans or insurers were required by the 2010 IFRto include diagnosis and treatment codes (and their
corresponding meanings) on all adverse benefit determinations.
Amended Rules: Health plans or insurers are required to include a statement on adverse benefit
determinations notifying members of their opportunity to request the related diagnosis and
treatment codes (and their meanings), and to provide such information upon request.
Non-English Language Assistance:
Health plans and insurers were required by the 2010 IFR to provide non-English language assistance and translation
of claims and appeals notices when certain thresholds of non-English language literacy were met. These thresholds
varied depending on whether a member had individual or group coverage.
Amended Rules: Non-English assistance for all members is based on whether the member resides in
a county in which 10 percent or more of the population is literate only in the same non-English
language. The Amended Rules list 225 U.S. counties in which this threshold was met as of June 22,
2011—in most of these counties, the non-English language is Spanish. Notices sent to addresses in one
of these 225 counties must include a statement in the applicable non-English language indicating how to
access language services. The health plan or insurer must provide oral language services in the non-
English language, and written notices in the non-English language upon request.