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New Federal Health Claims & Appeals Laws & Regulations for 193 Million Americans Effective 09-23-2010 ©2010, Jin Zhou, ERISAclaim.com
President Obama Signing Health Bill on 03/23/2010		President Gerald R. Ford Signing ERISA on 09/02/1974
New Webinars, Seminars & Certification Classes Announced for New Federal Health Claim Appeals Regulations on July 22, 2010 from HHS, DOL & IRS, Effective On Sept. 23, 2010 for 193 Million Americans
	UNITED STATES DEPARTMENT OF LABOR (Links to DOL) ©2010, Jin Zhou, ERISAclaim.com
Patient Protection and Affordable Care Act Statutory Laws [PDF] [PDF]   Affordable Care Act Regulations and Guidance Regulations on Internal Claims and Appeals and External Reviews: Interim Final Rule • Amendment to IFR • Corrections •  NAIC Uniform External Review Model Act  • News Release • Fact Sheet •  Public Comments Guidance, EOB’s & FAQ’s: TR11-02 • TR11-01 • TR10-02 • TR10-01 • EOB1 • EOB2 • EOB3 • FAQ I • FAQ II • FAQ III •  FAQ IV •  FAQ V • FAQ VI •  Consumer Assistance Programs Grandfathered Health Plans: Regulation •  Fact Sheet on Regulation • FAQ’s •  Summary Chart • Model Notice •  Amendment to IFR • Fact Sheet on Amendment Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections: Regulation • Fact Sheet • Patient Protection Model Notice • Lifetime Limits Model Notice • Dependents Model Notice  Extension of Coverage For Adult Children:  Regulation •  Fact Sheet • FAQs • IRS Guidance FAQs on Health Care Reform and COBRA   Affordable Care Act Compliance Assistance Webcast Series Archive: Part I • Part II House Committees Health Insurance Reform at a Glance: Summary • Implementation Timeline • Consumer Protections • For Employers White House Web Page on Health Reform HHS Health Reform Web Site
Employee Retirement Income Security Act — ERISA
ERISA Claims Regulation - 29 CFR 2560.503-1: Regulation • FAQ • Fact Sheet • Claims Guide • Claims Card ERISA SPD Regulation - 29 CFR 2520.102-3: Amendments to Summary Plan Description Regulations • Fact Sheet • News Release • SPD Rights Fact Sheet • SPD from DOL   Health Claims Related Information Consumer Information on Health Plans Compliance Assistance for Health Plans •  Fiduciary Guide Health Benefits Education Campaign
Webinars, Seminars & Certification Classes for New Federal Health Claim Appeals Regulations   ERISAclaim.com - Free Webinars - New Federal Claims & Appeals Regulations, Effective Sept. 23, 2010, for 193 Million Americans   ERISAclaim.com: Seminars - 2010 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals   ERISAclaim.com - 2010 PPACA & ERISA Claim Specialist Certification Programs in Chicago, Illinois   ERISAclaim.com:  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)

03/23/2010

Breaking News

President Obama Signed Into the Law the Healthcare Legislation to Revamp Healthcare Reimbursement Laws for All Group Health Plans and Health Care Providers

The Final Health Reform Bill Has Been Signed By President Obama Into The Law Of The Land For More Than 95% Americans, As The Most Significant Changes Since Medicare Was Created 45 Years Ago. What Does Obama Healthcare Law Mean To Healthcare Providers And Health Plans? The New Federal Reimbursement Laws Protect Health Care Providers with ERISA Internal And External Appeals, Extended Disclosure And Appeal Rights, New Federal UCR Fee Centers And New Federal Simplified, Uniform Standards For Claim Processing And Appeals. The New Federal Reimbursement Laws Will Eventually Eliminate Most Managed care Abuses

On March 23, 2010, President Obama signed into law the Senate Bill passed in the House of Representatives, making this year-long debated healthcare legislation into the law of land for more than 95% of Americans, with most significant overhaul to U.S. healthcare delivery system and reimbursement laws. What does this new Obama health law mean to healthcare providers? Lack of Information, Misinformation and Frustrations are faced by all on New Obama Health Reimbursement Laws. Health care providers should be informed of all specific and accurate statutory provisions on all new Obama health law mandates for claim appeals. Although the House amendment Bill to Senate Bill has to be taken up by the Senate and signed into law by President Obama later this week, statutory provisions on appeals and reimbursement laws were not amended by the House, thus the Senate Bill signed by President Obama is final for claims processing and appeals.

According to Dr. Jin Zhou, president of ERISAclaim.com, a national ERISA expert, and reimbursement compliance consultant, contrary to popular misinformation, the Obama health law, Patient Protection and Affordable Care Act, has established significant consumer protections and plan claim processing and appeal simplification to reduce administrative costs and enhance provider reimbursement rights and patient protections. New Obama health law incorporates or adopts existing ERISA claim regulation in its entirety as internal ERISA appeal mandates, and Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners as external ERISA appeal mandates as final and binding authority to all parties, in absence of judicial appeals. New Obama health law upgraded and extended existing ERISA appeal regulation with new EOB requirements, greater patient and provider rights to access to entire claim file and to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process. New Obama health law also established federal UCR (Usual, Customary and Reasonable) fee center to track and publish UCR fee schedules to the public, to end most commonly disputed reimbursement nightmares for all parties. Every group health plan and health care providers have six months after enactment of the act to come into complete compliance with new Obama health reimbursement laws. To ensure every patient and provider appeal rights, new Obama health law provides consumer assistance on mandatory ERISA internal and external appeals. More compliance and mandate information will be discussed at the webinar.

“After the legislation becomes the law of land for America health care, it is time for everyone who truly cares about reimbursement and compliance to forget about yesterday's legislation enthusiasm, set aside personal emotions and political preferences, to get hands on today’s new reality, statutory and regulatory compliance and reimbursement by learning and mastering new rule of the game for health care reimbursement through compliance”, said Dr. Jin Zhou, president of ERISAclaim.com.

Dr. Zhou also explains that ERISA has been the only governing federal law for claims denials and appeals procedures for about 176 million Americans covered under employment-based health plans for the past 35 years.

Although the new Obama health law will not convert non-ERISA plans to statutorily defined ERISA plans, this new health law will adopt existing ERISA claim regulation and state external review model act from NAIC for additional 32 million Americans.

ERISA Appeals Are No Longer A Choice, But Mandates And Compliance For All.

Sec. 2719, (a)(2)(A) of Patient Protection and Affordable Care Act provides the following:

“`SEC. 2719. APPEALS PROCESS.

 

`(a) Internal Claims Appeals-

 

`(1) IN GENERAL- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum—

 

`(A) have in effect an internal claims appeal process;

 

`(B) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the appeals processes; and

 

`(C) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process.

 

`(2) ESTABLISHED PROCESSES- To comply with paragraph (1)—

 

`(A) a group health plan and a health insurance issuer offering group health coverage shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70256), and shall update such process in accordance with any standards established by the Secretary of Labor for such plans and issuers; and

 

`(B) a health insurance issuer offering individual health coverage, and any other issuer not subject to subparagraph (A), shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures set forth under applicable law (as in existence on the date of enactment of this section), and shall update such process in accordance with any standards established by the Secretary of Health and Human Services for such issuers.

 

`(b) External Review- A group health plan and a health insurance issuer offering group or individual health insurance coverage—

 

`(1) shall comply with the applicable State external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans; or

 

`(2) shall implement an effective external review process that meets minimum standards established by the Secretary through guidance and that is similar to the process described under paragraph (1)—

 

`(A) if the applicable State has not established an external review process that meets the requirements of paragraph (1); or

 

`(B) if the plan is a self-insured plan that is not subject to State insurance regulation (including a State law that establishes an external review process described in paragraph (1)).

`(c) Secretary Authority- The Secretary may deem the external review process of a group health plan or health insurance issuer, in operation as of the date of enactment of this section, to be in compliance with the applicable process established under subsection (b), as determined appropriate by the Secretary.”

ERISA Claim Regulation, the section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000, can be found on the Website of Department of Labor, DOL:

< http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm>

New Obama Health Law Eliminate Your UCR Nightmares By Establishing Federal UCR Centers

Sec. 2719A of  Patient Protection and Affordable Care Act provides the following:

“SEC. 2719A. PATIENT PROTECTIONS.

 

`(d) Medical Reimbursement Data Centers-

 

`(1) FUNCTIONS- A center established under subsection (c)(1)(C) shall—

 

`(A) develop fee schedules and other database tools that fairly and accurately reflect market rates for medical services and the geographic differences in those rates;

 

`(B) use the best available statistical methods and data processing technology to develop such fee schedules and other database tools;

 

`(C) regularly update such fee schedules and other database tools to reflect changes in charges for medical services;

 

`(D) make health care cost information readily available to the public through an Internet website that allows consumers to understand the amounts that health care providers in their area charge for particular medical services; and

 

`(E) regularly publish information concerning the statistical methodologies used by the center to analyze health charge data and make such data available to researchers and policy makers.

 

`(2) CONFLICTS OF INTEREST- A center established under subsection (c)(1)(C) shall adopt by-laws that ensures that the center (and all members of the governing board of the center) is independent and free from all conflicts of interest. Such by-laws shall ensure that the center is not controlled or influenced by, and does not have any corporate relation to, any individual or entity that may make or receive payments for health care services based on the center's analysis of health care costs.”

<http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.3590.eas:>

More Exclusive Legal Documents on Patient Protection And Affordable Care Act Are Available On Senate Democratic Policy Committee < http://dpc.senate.gov/dpcdoc-sen_health_care_bill.cfm>

Immediate Benefits:

Immediate Benefits < http://dpc.senate.gov/healthreformbill/healthbill46.pdf>

Implementation Timeline < http://dpc.senate.gov/healthreformbill/healthbill50.pdf>

More Legal Documents on House Amendment Are Available From Committee of Rules Of The U.S. House Of Representatives

 <http://www.rules.house.gov/bills_details.aspx?NewsID=4606>

Text of the Amendment to the Amendment in the Nature of a Substitute

< http://docs.house.gov/rules/hr4872/111_managers_hr4872.pdf>

Summary of the Amendment to the Amendment in the Nature of a Substitute

< http://www.rules.house.gov/amendment_details.aspx?NewsID=4611>

Text of the Amendment in the Nature of a Substitute

< http://docs.house.gov/rules/hr4872/111_hr4872_amndsub.pdf>

Section-by-Section of the Amendment in the Nature of a Substitute

< http://www.rules.house.gov/111_hr4872_secbysec.html>

Text of the Senate Amendments to H.R. 3590 (Senate health bill)

< http://docs.house.gov/rules/hr4872/111_hr3590_engrossed.pdf>

President Obama Wanted You To Do New ERISA Appeals If You Feel You Were Unfairly Denied A Claim

            For healthcare providers and patients, President Barack Obama explained this new ERISA Appeals on Jan 09, 2010:

“WASHINGTON – In his weekly address, President Barack Obama discussed the benefits of health reform that Americans will receive in the first year, and how reform will help build a new foundation for American families.  After reform becomes law, uninsured Americans with a pre-existing condition will be able to purchase affordable coverage, insurance companies will be prohibited from imposing lifetime and annual limits on care, small business will receive tax credits to purchase coverage for their employees, along with many other changes.  In short, patients and doctors will have more control over health care decisions, and insurance company bureaucrats will have less.”

“And there will be a new, independent appeals process for anyone who feels they were unfairly denied a claim by their insurance company."

Weekly Address: President Obama Outlines Benefits of Health Reform to Take Effect This Year <http://www.whitehouse.gov/the-press-office/weekly-address-president-obama-outlines-benefits-health-reform-take-effect-year>

The Official Interpretation on Time line for ERISA Internal and External Appeals from Senate Democratic Policy Committee:

“Appeals Process

ü Under the Patient Protection and Affordable Care Act, all new health plans will implement, within six months of enactment, an effective process for appeals of coverage determinations and claims. And, states will provide an external appeals process to ensure an independent review.”

< http://dpc.senate.gov/healthreformbill/healthbill46.pdf>

Free New Obama Health Law Webinars, as a continuation of ERISAclaim.com monthly webinar for past two months on the subject, will now be offered on daily basis for several weeks, weekly basis for two months and monthly basis for the rest of 2010 in the wake of the President Obama signing into law the most significant healthcare reform in America and urgent and tremendous amount of demand from healthcare providers and health plans. The time for each free webinar is 60 minutes, from 11 AM to 12 PM central standard time. Registration is free for all. The Webinar Handout is also available and free to download at: http://www.erisaclaim.com/Free_ERISA_Webnars.htm.

The New Obama Healthcare Reimbursement Law weekly and monthly Webinars, ERISA Claim Specialist Certification Programs and ERISA Appeal Department Programs were also available from ERISAclaim.com because ERISA Internal and External Appeals are now mandatory for all group health plans and healthcare providers under new Obama Healthcare Reform Laws.

In the past 10 years, ERISAclaim.com has been the only ERISA Specialized Company offering the most practical and comprehensive ERISA education, consulting and publishing services for healthcare providers in administrative ERISA appeals for real problem oriented denials under the most mysterious 35-year-old federal law, ERISA. Dr. Jin Zhou, president ERISAclaim.com has been regarded as the Godfather of ERISA claims for healthcare providers by some in Professional billing and coding industry.

For more information or to arrange an interview, please contact Dr. Jin Zhou, president of ERISAclaim.com at 630-808-723 and ERISAclaim@aol.com or visit: <http://www.erisaclaim.com/Free_ERISA_Webnars.htm>

###

Healthcare Reform News Letter

01/05/2010

The New Healthcare Reform Is Final on Provider Reimbursement Laws:

ERISA Appeals Procedures Mandatory for All Group Health Plans and Healthcare Providers

The Final Health Bill Passed In Senate On Christmas Eve Is Completely Consistent With House Health Bill By Incorporating ERISA Claim Regulation In Its Entirety For All Group Health Plans Into Obama Health Reform, For 200 Million Americans Under New Obama Universal Healthcare Laws. ERISA Appeal Process Is Now Mandatory For All Group Health Plans And Healthcare Providers As Well As Consumers. First Free Monthly ERISA Webinar starts on 01/18/2010, and First Advanced ERISA Claim Specialist Certification Program Starts in Feb. 2010.

Hanover Park, IL, Jan. 05, 2010 – The final Managers' Amendment of Senate Health Bill, HR3590, Patient Protection and Affordable Care Act added a special section, Sec. 2719, (a)(2)(A), to incorporate ERISA claim regulation, 29 CFR §2560.503.1 in its entirety for all group health plans and all health insurance Companies offering group health coverage. The final Senate Bill is completely consistent with House Bill, HR3962, Affordable Health Care for America Act, which has the exact same ERISA provision in the Sec. 232, Requiring Fair Grievance And Appeals Mechanisms. Therefore, the new health care reimbursement laws from Obama Healthcare Reform are completely a done deal from legislation in the making as a matter of “what”, for all payers and providers. ERISA will be the only governing federal law for claims denials and appeals procedures for group health plans after January of 2010 for an additional 30 million Americans who are otherwise uninsured today. ERISA has been the only governing federal law for claims denials and appeals procedures for about 170 million Americans covered under employment-based health plans for the past 35 years. The new ERISA appeal provision will be effective immediately upon the enactment of the Health Bill, and all group health plans will have 6 months after the enactment of the Act to come into complete compliance with appeals provisions of the new Obama federal healthcare laws.

ERISA Claims Procedures Are Mandatory For All Group Health Plans and All Healthcare Providers

The final Senate Health Bill, HR3590, Patient Protection and Affordable Care Act added a special section, Sec. 2719, (a)(2)(A), which provides the following:

‘‘(2) ESTABLISHED PROCESSES.—To comply with paragraph (1)—

(A) a group health plan and a health insurance issuer offering group health coverage shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70256), and shall update such process in accordance with any standards established by the Secretary of Labor for such plans and issuers; and”

< http://democrats.senate.gov/reform/managers-amendment.pdf>

The Sec. 232 (b) of House Bill, HR3962, Affordable Health Care for America Act, provides the following:

“Section 232, Requiring Fair Grievance And Appeals Mechanisms.

(b) Internal Claims and Appeals Process- Under a qualified health benefits plan the QHBP offering entity shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70246) and shall update such process in accordance with any standards that the Commissioner may establish.”

< http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.3962.pcs:>

ERISA Claim Regulation, the section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000, can be found on the Website of Department of Labor, DOL:

< http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm>

As stated by Robert Gibbs at his White House Press Briefing on December 22, 2009, “health care reform is not a matter of if; health care reform now is a matter of when”. It is widely reported that President Obama is expected to sign the merged Senate and House final bill into the law before he delivers the State of the Union address in mid-January 2010.

“Immediate Benefits” and How to Benefit Within Six Months Of Enactment?

As explained by Senate Democratic Policy Committee, the maker of the Senate Health Bill,

“The Patient Protection and Affordable Care Act includes health insurance market reforms that will bring immediate benefits to millions of Americans, including those who currently have coverage. The Managers’ Amendment to the bill includes even more early benefits for Americans, and the following benefits will be available in the first year after enactment of the Patient Protection and Affordable Care Act”.

 <http://dpc.senate.gov/healthreformbill/healthbill46.pdf>

A copy of the “Immediate Benefits” relevant to providers is captioned at the end of the news letter.

In order to benefit from all of these immediate expanded coverage reimbursements, healthcare providers must master ERISA claims procedures and appeal process, as all group health plans are mandated to come into complete compliance within six months of the enactment, as summarized by the Senate Democratic Policy Committee:

“Appeals Process

ü Under the Patient Protection and Affordable Care Act, all new health plans will implement, within six months of enactment, an effective process for appeals of coverage determinations and claims. And, states will provide an external appeals process to ensure an independent review.”

<http://dpc.senate.gov/healthreformbill/healthbill46.pdf>

ERISA appeals procedures were claimed as one of the health insurance reform solutions by the White House Office of Health Reform, as posted in The White House Blog, Where the Road to Health Reform Began, on December 29, 2009 at 11:05 AM EST:

“Health Insurance Reform Solution: Reform will end insurer abuses, lower premiums, and hold insurance companies accountable…….And consumer rights will be enhanced by requiring all insurers to provide effective appeals procedures including outside, independent review of appeals.”

After the New Year, as soon as Congress begins the task of merging the Senate Bill with the House Bill for Obama’s signature, the Congress and the main stream media will be busy in explaining to the American people how the new Obama Health Reform would affect people who already have health coverage through employment-based plans and also people who are not otherwise insured today, and who will really be responsible for paying for the universal coverage.

“But, no one is talking about the real important enforcement issues, as the new solution in Obama Health Reform, for ERISA claims and appeals process as the final step of health care delivery, for about 200 million Americans”, said Dr. Jin Zhou, the president of ERISAclaim.com, the nation’s leading expert in ERISA claims appeals.

“We must realize that whether the entire U. S. healthcare delivery system under Obama Health Reform will succeed or fail finally depending upon whether the new universal care can or will be paid for, properly to the healthcare providers by the health plans and insurance companies, or the claims disputes can be resolved effectively under the new Obama Health Reform with ERISA appeals procedures”, as explained by Dr. Jin Zhou of ERISAclaim.com.

"Entrepreneurs will benefit. Patients and survivors of diseases will benefit. Americans of different backgrounds and ethnicities will benefit," as Senate Majority Leader Harry Reid of Nevada said last month.

Dr. Zhou further stated that “entrepreneurs from health plans and healthcare providers must now comply with and master ERISA claim regulations in order to benefit under the new healthcare legal and market environment, to either get paid or contain the costs legitimately.”   

ERISAclaim.com Can Help You Get Paid Through Compliance

In order to help healthcare providers to get all the benefits from the new Obama health reform, ERISAclaim.com will offer free monthly Webinars, starting on Jan. 18, 2010, to educate healthcare providers and health plans to come into compliance “within six months of enactment” with new federal reimbursement laws, as required for all group health plans, under the Patient Protection and Affordable Care Act.

ERISAclaim.com will also offer basic ERISA Claims and Appeals Seminars and Advanced ERISA Claim Specialist Certification Programs (ECSC), starting in Feb 2010.

In the past 10 years in USA, ERISAclaim.com has been the only ERISA Specialized Company offering the most  practical and comprehensive ERISA education, consulting and publishing services for healthcare providers in administrative ERISA appeals for real problem oriented denials under the most mysterious 35-year-old federal law, ERISA.

For more information or to arrange an interview, please visit http://www.erisaclaim.com/certification.htm, or contact Dr. Jin Zhou, president of ERISAclaim.com, at 630-808-7237.

###

Official Document on “Immediate Benefits” from Senate Democratic Policy Committee, the Maker of the Senate Health Bill, The Captioned Are Only Relevant to Healthcare Providers:

<http://dpc.senate.gov/healthreformbill/healthbill46.pdf>