Your Explanation of Benefits are Changing
Recent healthcare reform regulations required all non-grandfathered health plans, whose first plan year began on or after July 1, 2011, to comply with the Department of Labor's (DOL) regulations regarding the processing of internal and external appeals. Affected plans include both fully insured and self-funded plans, regardless of the plan being either an ERISA governed plan or non-ERISA plan. In addition, plans were to include the corresponding meanings of diagnostic codes and treatment codes on all adverse benefit determinations. In certain instances, an EOB is considered an adverse benefit determination.
This regulation has since been revised and code meanings are no longer required. However, EOBs must now contain a statement that diagnostic and treatment code meanings are available upon request.
Meritain Health has enhanced its EOBS, based on the model notices issued by the DOL, to assist plans with complying. This new requirement applies only to non-grandfathered plans; however, as a growing number of clients are relinquishing grandfather status, we have enhanced all EOBs with additional appeals language. The detailed appeals language will now appear on the back of the last page of the EOB.
For a sample of the enhanced appeals language, click here.
Please remember, if an appeal filing limit is longer or shorter than the 180-day limit, the number of days available to appeal a claim has been revised accordingly.
Please also note, a box has been added to the last page of the EOB, offering assistance to plan participants whose predominant language is not English. This additional content is intended to alert non-English-speaking participants that our customer service number is available for plan assistance. This text is translated into all four languages currently required by healthcare reform regulations.
The new language assistance has been added due to a healthcare reform requirement that adverse benefit determinations contain "culturally and linguistically appropriate" language. Although it is only required when plan participants reside within a particular zip code, its addition is in an attempt to avoid tracking participants based on the county where they reside.
Additionally, as a privacy enhancement, Meritain Health is in the process of reviewing all our systems to ensure EOBs are sent directly to the patients who have received the service listed.
For more information about these recent updates, or if you have any questions, please contact your Client Relationship Manager or Meritain Health representative.