On March 1, 2013, the Department of Labor (DOL) released new and detailed PPACA self-compliance guidance for full implementation of PPACA Coverage and Claims Appeals Regulations, also known as the Provider Bill Of Rights. Healthcare Providers as well as Health Plans are urged to comply with PPACA in accordance with DOL’s Self Compliance Guidance, the most comprehensive “Self Compliance Tools” for the nation’s health plans and healthcare providers since the Supreme Court upheld PPACA’s constitutionality on June 28, 2012.
In conjunction with the DOL’s issuance, Avym announces unique PPACA claim appeals compliance programs for BOTH healthcare providers and health plans, as intended by Congress to protect all patients under the Patient Protection and Affordable Care Act. PPACA is also known as the Patient Bill Of Rights by Congress and the White House. With the DOL’s self-compliance guidance and particularly the claims denial and appeals protections, PPACA can now be defined as the “Provider Bill of Rights” under PPACA claims regulation.
In issuing these comprehensive PPACA Self Compliance Tools, the DOL has stated the scope and importance of PPACA compliance for everyone: “This self-compliance tool is useful for group health plans, plan sponsors, plan administrators, health insurance issuers, and other parties to determine whether a group health plan is in compliance with some of the provisions of Part 7 of ERISA….. Under the Affordable Care Act, there are various provisions that apply to group health plans and health insurance issuers and various protections and benefits for consumers that are beginning to take effect or that will become effective very soon.”
The entire DOL Self Compliance Tools may be found at DOL website:
PPACA coverage and claims appeals regulations provide expanded consumer coverage and claims denial and appeal protections. PPACA adopts ERISA (the federal law in existence for 37 years) in its entirety as the minimum internal appeals standards, with additional consumer and provider protections. PPACA also provides federal external appeal protections. DOL PPACA and ERISA self-compliance tools are in forms of the most comprehensive questions for health plan payers to determine compliance according to DOL:
“Internal Claims and Appeals
Under the Affordable Care Act group health plans and health insurance issuers offering group health insurance coverage were required to implement an effective internal claims and appeals process for plan years beginning on or after September 23, 2010. In general, the interim final regulations require plans and issuers to comply with the DOL claims procedure rule under 29 CFR 2560.503-1 and impose specific additional requirements and include some clarifications (referred to as the “additional standards” for internal claims and appeals). In addition to meeting the following requirements, the plan is required to comply with all of the requirements of the DOL claims procedure rule under 29 CFR 2560.503-1.
The following questions have been developed to assist in determining compliance with the additional standards for internal claims and appeals processes.”
With respect to Providers Bill of Rights, one of the most important new PPACA protections for all providers, according to the DOL, is the following:
“Question 2 – Does the plan provide claimants with any new or additional evidence or rationale considered in connection with a claim?
The Department’s regulations clarify that plans or issuers must provide to claimants, free of charge, any new or additional evidence considered, relied upon, or generated by (or at the direction of) the plan or issuer in connection with a claim. This evidence must be provided as soon as possible and sufficiently in advance of the date on which the notice of final internal adverse benefit determination is required to be provided in order to give the claimant a reasonable opportunity to respond prior to that date. Similarly, before a plan or issuer can issue a final internal adverse benefit determination based on a new or additional rationale, the claimant must be provided, free of charge, with the rationale. This rationale must be provided as soon as possible and sufficiently in advance of the date on which the notice of final internal adverse benefit determination is required to be provided in order to give the claimant a reasonable opportunity to respond prior to that date. See 29 CFR 2590.715-2719(b)(2)(ii)(C).
This provision is applicable for plan years beginning on or after September 23, 2010. See 29 CFR 2590.715-2719(g).” http://www.dol.gov/ebsa/pdf/part7-2.pdf
The new Avym PPACA training partnership programs will explore possibilities to:
- Create partnership networks nationwide to immediately offer Certified PPACA & ERISA Claim Specialist Programs, same as Medicare claims and compliance for 45 years;
- Create awareness and readiness to develop a national network or association for PPACA & ERISA Claim Specialists.
To find out more about PPACA Claims and Appeals Compliance Services from AVYM, please click here.
Located in Los Angeles, CA, Avym is a leading provider of services focusing entirely on the resolution of denied or disputed medical insurance claims by participating in the nation’s first ERISA/PPACA Claims Appeals Certification program. Avym also offers webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support.