ERISA/Employee Benefits-DOL Issues Interim Federal Procedures For Reviewing Group Health Plan External Claims

In Technical Release 2010-01, the Department of Labor (the “DOL”) issued Federal procedures for reviewing external claims from group health care plans.

By way of background, Section 2719 of the Public Health Service Act (the “PHS Act”), as in effect after recent healthcare legislation, generally applies to group health plans which are not “grandfathered” health plans (a “grandfathered” plan is generally a plan in existence on March 23, 2010). Section 2719 sets forth standards for covered plans regarding both internal claims and appeals and external review of those claims. It applies in any plan year starting on or after September 23, 2010. The DOL (along with the Internal Revenue (the “IRS”) and the Department of Health and Human Services) published interim final regulations implementing Section 2719 on July 23, 2010. However, those regulations did not establish the requirements for Federal procedures for reviewing external claims. Technical Release 2010-01 fills that gap.

The Federal procedures for reviewing external claims apply to covered self-insured group health plans, and any covered insured health care whose insurer is not subject to State external claims review procedures that meet the requirements of Section 2719 of the PHS Act. The new Federal procedures include rules for requests by participants for external review, a preliminary review of the requests, referral of the claims to independent reviewing organizations and expedited reviews for serious medical conditions.

The Federal procedures in the Technical Release are considered to be a “safe harbor”. Therefore, neither the DOL nor the IRS will take any enforcement action, with respect to Section 2719 of the PHS, against any covered plan, to which the Federal procedures apply, that complies with the procedures described in the Technical Release.

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