HR Magazine, March 2001: More Leeway for Workers, More Work for HR - Other Important Changes for Group Health Plans 

 

The final regulations make other important changes that apply principally to group health plans. These changes include the following:

• An authorized representative of a claimant must be allowed to act on behalf of the claimant. For purposes of an urgent care claim, the regulations specifically provide that a health care professional with knowledge of a claimant’s medical condition must be treated as the claimant’s representative. A plan may establish reasonable procedures for determining whether an individual has been authorized to act on behalf of a claimant.

• The final regulations make health maintenance organization (HMO) plans fully subject to the new procedural standards.

• Group health plans governed by state insurance law may be subject to the state’s review procedure to evaluate and resolve disputes involving adverse determinations.