Vol. 46, No. 3
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.