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Posts: 397
Jul 23 03 7:59 AM
Banned User
Quote: For purposes of this subchapter: (1) The terms ''employee welfare benefit plan'' and ''welfare plan'' mean any plan, fund, or program which was heretofore or is hereafter established or maintained by an employer or by an employee organization, or by both, to the extent that such plan, fund, or program was established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or otherwise,
Quote: (3) The claims procedures do not contain any provision, and are not administered in a way, that unduly inhibits or hampers the initiation or processing of claims for benefits. For example, a provision or practice that requires payment of a fee or costs as a condition to making a claim or to appealing an adverse benefit determination would be considered to unduly inhibit the initiation and processing of claims for benefits. Also, the denial of a claim for failure to obtain a prior approval under circumstances that would make obtaining such prior approval impossible or where application of the prior approval process could seriously jeopardize the life or health of the claimant (e.g., in the case of a group health plan, the claimant is unconscious and in need of immediate care at the time medical treatment is required) would constitute a practice that unduly inhibits the initiation and processing of a claim;
Quote: (1)(i) A ``claim involving urgent care'' is any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations-- (A) Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, or, (B) In the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. (ii) Except as provided in paragraph (m)(1)(iii) of this section, whether a claim is a ``claim involving urgent care'' within the meaning of paragraph (m)(1)(i)(A) of this section is to be determined by an individual acting on behalf of the plan applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine. (iii) Any claim that a physician with knowledge of the claimant's medical condition determines is a ``claim involving urgent care'' within the meaning of paragraph (m)(1)(i) of this section shall be treated as a ``claim involving urgent care'' for purposes of this section.
Quote:(4) The claims procedures do not preclude an authorized representative of a claimant from acting on behalf of such claimant in pursuing a benefit claim or appeal of an adverse benefit determination. Nevertheless, a plan may establish reasonable procedures for determining whether an individual has been authorized to act on behalf of a claimant, provided that, in the case of a claim involving urgent care, within the meaning of paragraph (m)(1) of this section, a health care professional, within the meaning of paragraph (m)(7) of this section, with knowledge of a claimant's medical condition shall be permitted to act as the authorized representative of the claimant;
Quote:Faster Decisions Faster decisions on initial claims - rather than 90 days (or more) under current regulation, the new rule would require decisions (in most cases) not later than: 72 hours for urgent care claims 15 days for pre-service claims 30 days for post-service claims One 15 day extension for pre- and post-service claims