tci Medicare Compliance & Reimbursement - 2011 Issue 17

Follow These New Regulations

In addition to requiring a standardized explanation of benefits (EOB) and allowing the provider to become a claimant, the final PPACA regulations also set forth the following new requirements of which your practice should be aware: Clarification of the meaning of adverse benefit determination -- this means that rescission of coverage is considered a denial and patients can use the entire ERISA appeals process to fight the denial/policy cancellation. Expedited urgent care determination -- this regulation stated that insurance companies had to determine benefits involving urgent care within 24 hours. This requirement was "cancelled," Zhou explains. "The urgent...

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