Urgent claims under the DOL Regs

[Linda]

Under the DOL’s new claims regs, I understand that a provider can force a group health plan to treat a “pre-service health claim” as “urgent.” But what about a plan that does not have pre-certification requirements (or other requirements for advance approval)? Can a provider force a plan to adjudicate a claim within the 72 hours, where the plan does not have penalized the participant for failure to get advance approval?

Any insight as to how the claims regs might fare under the Bush adminsitration? Should we still expect to have to comply in 2002?

[jeanine]

My understanding of the regs is that the turn around time has more to do with the provision of services to the enrollee, rather than the provision of payment to the physician. If the service is already rendered, there's no urgency. Maybe I'm misunderstanding your question. Our concern about these regs is, as a TPA, what happens if the Plan is not funding timeley to meet the payment turnaround times. I'm guessing that not even a Bush administration will prevent or change the claims regs. I suppose there still is hope that the Privacy regs just issued will be reevaluated by a Bush administration.