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

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HR Magazine, 
March 2001 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.
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