Vol. 46, No. 3
Employers and plan administrators should consider taking the following action as soon as possible:
- Review group health plan and disability plan claims procedures and assess ways to streamline them so that claims and appeals can be processed in compliance with the new expedited time frames. The assessment should take into account:
- Required second-tier review.
- Required consultation with a health care professional.
- Potential required disclosure of "relevant" documents if a claim is denied.
- Develop and follow formal written claims procedures for each plan that will be available to participants.
- Prepare model letters to comply with the new notice and disclosure requirements for claims procedures.
- Increase staff to expeditiously process claims, especially urgent claims, which will require weekend staff.
- Contract with insurers and third-party administrators to ensure compliance with the new requirements for claims procedures.
- Review and revise group health plan SPDs to include required information on medical benefits and providers.
- Review and revise all SPDs to include information on plan amendments and terminations and, for participant-directed plans, a reference to ERISA section 404(c), if applicable.
- Review all SPDs to determine what information should be added to comply with the new disclosure requirements.
- Review and revise group health plan SPD disclosures with respect to maternity hospital stays and, if applicable, health insurer information.