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Health Plan Investigations: The ACA's 'Prudent Layperson' Standard
Groom Law GroupLink to more items from this source
[Guidance Overview]
Nov. 3, 2021

"[In] the preamble to the interim final rule 'Requirements Related to Surprise Billing; Part I,' DOL, [HHS], and Treasury explained that denials cannot be based solely on diagnosis code and must instead be evaluated under the prudent layperson standard.... The practical effect is that the agencies have codified DOL's enforcement position under the ACA's emergency services rule that the use of a True ER List is impermissible as a sole basis to deny claims."

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