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A Better Partnership


Mar 2011
March 29, 2011

Health Care Reform and Claims Procedures

Often-overlooked among the changes required by Health Care Reform are revisions to procedures for claims and appeals — both internal and external. These changes impact: deadlines for making pre-certification decisions on urgent care claims, communications about claims and claims appeals, the scope of claims appeals and the remedies available once a participant has exhausted the internal claims appeals process. These rules apply to non-grandfathered medical plans, including most health reimbursement arrangements (HRAs) and some flexible spending accounts (FSAs).

Although these new requirements were originally scheduled to go into effect for plan years beginning on and after September 23, 2010, the Department of Labor extended some of the deadlines until July 1, 2011 — and now has additionally extended some deadlines until plan years beginning on or after January 1, 2012. A complete list of these requirements and their implementation deadlines can be found here.

If a third-party administrator (TPA) handles your claims appeals process, then it may be worth having a discussion to determine whether it is on schedule to comply with these deadlines. You may want to ask for a sample of the TPA’s current explanation of benefits to verify that it complies with the requirements that are already enforceable. Also, some employers handle final claims appeals, or even self-administer certain health benefits that are subject to these rules. If this is true for your plan, then you should also examine your own claims and appeals practices and communications to make sure that you are in compliance with the new requirements. An employer who is not in compliance could face penalties of up to $100 per day per participant, plus ERISA enforcement actions.

If you have any questions about claims procedures or about Health Care Reform in general, please contact Norbert F. Kugele ( or 616.752.2186) or any other member of the Health Care Reform Taskforce at Warner Norcross & Judd.

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