What are the claims and appeals procedures under ERISA?
Apr 13, 2022 · ERISA law also establishes appeal regulations that allow beneficiaries the right to appeal the denial of treatment and appeal claims that are denied and not paid. The regulations also require the employer’s plan administrator to cite the sources used when making a claim decision and the credentials of the claim reviewer.
What is the procedure for appeal of adverse benefit determination?
least, the plan’s appeal procedure must let you or your authorized representative do the following: 1. Request a review in writing 2. Review relevant documents 3. Submit issues and comments in writing. Filing an Appeal. To file an appeal, follow the appeal procedure of your insurance plan. You can ask for the appeal procedure in writing from the company.
What is a reasonable opportunity to appeal a benefit determination?
Accordingly, while the department is of the view that plans must afford claimants a reasonable period of time within which to develop their appeal of a proposed reduction or termination, plans are not required to assume that claimants will need the full 180 days to file such an appeal before the benefit can be reduced or terminated under the special rules governing concurrent …
Can I appeal a group health plan's decision to reduce benefits?
If all or part of the participant's claim is denied, the participant may request an appeal. The participant must request a review of the denied claim in writing within 180 days after receiving notice of the denial. The participant's request should be …
A-1: Does The Regulation Apply to Benefit Claims Filed by Enrollees in Federal Programs, Such as Medicare and Medicaid, Or to Federal Employees and Their Families Covered Under The Federal Employees Health Benefits Program (Fehbp)?
No. The regulation establishes requirements only for employee benefit plans that are covered under ERISA. See ERISA sections 3(1) and 3(2). Such pl...
A-2: Does The Regulation Apply to Benefit Claims Filed by Persons Who Are Both Enrollees in Medicare + Choice Programs and Participants in An ERISA Plan?
The regulation applies only to benefits provided under an ERISA plan that are outside the scope of what is regulated by the Medicare program. Benef...
A-3: Does The Regulation Apply to A Request For A Determination Whether An Individual Is Eligible For Coverage Under A Plan?
The regulation applies to coverage determinations only if they are part of a claim for benefits. The regulation, at § 2560.503-1(e), defines a clai...
A-4: Does The Regulation Apply to A Request For Prior Approval of A Benefit Or Service When Such Prior Approval Is Not Required Under The Terms of The Plan?
No. If the plan does not require prior approval for the benefit or service with respect to which the approval is being requested, the request is no...
A-5: Is A Plan Required to Treat All Questions Regarding Benefits as Claims For Benefits Under The Plan?
No. The regulation does not govern casual inquiries about benefits or the circumstances under which benefits might be paid under the terms of a pla...
A-6: Do The Requirements Applicable to Group Health Plans Apply to Dental Benefits Offered as A Stand-Alone Plan Or as Part of A Group Health Plan?
Yes, in both cases. The regulation defines group health plan as an employee welfare benefit plan within the meaning of ERISA section 3(1) to the ex...
A-7: Do The Requirements Applicable to Group Health Plans Apply to Prescription Drug Benefit Programs Offered as A Stand-Alone Plan Or as Part of A Group Health Plan?
Yes, in both cases. Prescription drug benefits would, like dental benefits, constitute medical care within the meaning of Section 733(a)(2). See qu...
A-8: Do The Requirements Applicable to Group Health Plans Apply to Contractual Disputes Between Health Care Providers (e.g., Physicians, Hospitals) and Insurers Or Managed Care Organizations (e.g., Hmos)?
No, provided that the contractual dispute will have no effect on a claimant's right to benefits under a plan. The regulation applies only to claims...
A-9: What Benefits Are Disability Benefits Subject to The Special Rules Applicable Under The Regulation For Disability Claims?
A benefit is a disability benefit under the regulation, subject to the special rules for disability claims, if the plan conditions its availability...
A-10: Do The Time Frames in These Rules Govern The Time within Which Claims Must Be Paid?
No. While the regulation establishes time frames within which claims must be decided, the regulation does not address the periods within which paym...
What is ERISA insurance?
The federal Employee Retirement Income Security Act (ERISA) sets the national standards for the claims and appeals procedures of private employer-based (self-insured) health insurance. Insurance plans may also be called health plans which means that insurance through your employer must, at the minimum, provide the protections set out in ERISA. ERISA does not currently apply to individually purchased insurance plans.
What to do if your unemployment plan denies your appeal?
If the plan denies your appeal, then you may contact the U.S. Department of Labor. You may also choose to seek legal assistance. You can contact your regional U.S. Department of Labor Employee Benefits Security Administration (EBSA) at:
How long can you extend your disability claim?
Like claims, extensions in special circumstances have a general 90-day maximum time limit, but the time frames may vary based on the type of claim. For both preservice and postservice claims decisions, the extension period is up to 15 days. Disability claims can have up to two separate 30-day extensions.
How long does it take to appeal an insurance claim?
The insurance company must make an appeal decision, in general, no later than 60 days after it receives your appeal notice. Appeals decisions, like original claims decisions, have different timelines based on the type of claim. The company may ask for an extension in special circumstances. If there is an extension, the company must make a decision no later than 120 days after receiving your request for review. If the plan needs an extension, the company must tell you in writing.
What to do if your insurance company doesn't tell you its decision?
If your insurance company does not tell you its decision for the original claim filed, even after the extension deadline, contact the company and ask for the decision in writing . If it does not send a decision in writing, contact your regional Employee Benefits Security Administration (EBSA) oce for assistance in receiving a formal approval or denial from your insurance company.
How long do you have to appeal an adverse benefit determination?
Under the regulation, claimants must be afforded at least 180 days following receipt of an adverse benefit determination to appeal that determination. In the case of a plan with a two-level review process, the 180-day rule applies to the period to be afforded claimants to appeal to the first review level.
What is the effective date of a health insurance policy?
The applicability date for claims other than group health claims is January 1, 2002.
What is a claim for benefits?
The regulation, at § 2560.503-1 (e), defines a claim for benefits, in part, as a request for a plan benefit or benefits made by a claimant in accordance with a plan's reasonable procedure for filing benefit claims.
What is a group health plan?
The regulation defines group health plan as an employee welfare benefit plan within the meaning of ERISA section 3 (1) to the extent that such plan provides medical care within the meaning of section 733 (a) of ERISA. See § 2560.503-1 (m) (6). Section 733 (a) (2) defines medical care, in part, to mean the diagnosis, cure, mitigation, treatment, ...
Can a pre-service claim be a claim for benefits?
No. If the plan does not require prior approval for the benefit or service with respect to which the approval is being requested, the request is not a claim for benefits (§ 2560.503-1 (e)) governed by the regulation. The regulation defines pre-service claim by reference to the plan's requirements, not the claimant's decision to seek the medical care, nor the doctor's decision to provide care. Thus, in the absence of any plan requirement for prior approval, mere requests for advance information on the plan's possible coverage of items or services or advance approval of covered items or services do not constitute pre-service claims under the regulation. See § 2560.503-1 (m) (2).
What is a disability benefit?
A benefit is a disability benefit under the regulation, subject to the special rules for disability claims, if the plan conditions its availability to the claimant upon a showing of disability. It does not matter how the benefit is characterized by the plan or whether the plan as a whole is a pension plan or a welfare plan.
Can a group health plan ignore pre-service inquiries?
No. The regulation does not govern casual inquiries about benefits or the circumstances under which benefits might be paid under the terms of a plan. On the other hand, a group health plan that requires the submission of pre-service claims, such as requests for preauthorization, is not entirely free to ignore pre-service inquiries where there is a basis for concluding that the inquirer is attempting to file or further a claim for benefits, although not acting in compliance with the plan's claim filing procedures. In such a case, the regulation requires the plan to inform the individual of his or her failure to file a claim and the proper procedures to be followed. Specifically, this type of notification is required where there is a communication by a claimant or authorized representative (e.g., attending physician) that is received by a person or organizational unit customarily responsible for handling benefit matters (e.g., personnel office) and that communication names the specific claimant, specific medical condition or symptom and a specific treatment, service, or product for which approval is requested. Under the regulation, notice must be furnished as soon as possible, but not later than 24 hours in the case of urgent care claims or 5 days in the case of non-urgent claims. Notice may be oral, unless a written notification is requested. See § 2560.503-1 (c) (1).
How long does it take to appeal a medical plan?
Urgent Care Appeals: As soon as possible considering the medical urgency, no later than 72 hours after the plan receives the participant's appeal. Pre-service Appeals: Within a reasonable period of time appropriate to the medical circumstances, no later than 30 days after the plan receives participant's appeal.
How long does it take to appeal an adverse decision?
If the participant disagrees with the decision on a claim, the participant (or an authorized representative) may file a written appeal with the plan within 180 days after receipt of the notice of adverse decision.
What is a concurrent care decision?
Concurrent Care Decision: Any decision in which the plan — after having previously approved an ongoing course of treatment provided over a period of time or a specific number of treatments — subsequently reduces or terminates coverage for the treatments ( other than by plan amendment or termination).
How long does it take for an urgent care claim to be notified?
If a properly filed urgent care claim is missing information needed for a coverage decision, the participant will be notified by the plan as soon as possible, but no later than 24 hours after the claim has been received by the plan.
What is an authorized representative?
Authorized Representative: An individual authorized to act on the participant's behalf in pursuing a claim or appeal in accordance with procedures established by the plan. For urgent care claims, a health care professional with knowledge of the participant's medical condition may act as an authorized representative.
What is an adverse decision?
Adverse Decision or Adverse Decision on Appeal: A denial, reduction, or termination of, or a failure to provide or make, payment (in whole or in part) for a benefit. An adverse decision includes a decision to deny benefits based on: An individual's being ineligible to participate in the plan; Utilization review; ...
What happens if a disability plan fails to comply with the requirements of the Act?
(i) In the case of a claim for disability benefits, if the plan fails to strictly adhere to all the requirements of this section with respect to a claim, the claimant is deemed to have exhausted the administrative remedies available under the plan , except as provided in paragraph (l) (2) (ii) of this section. Accordingly, the claimant is entitled to pursue any available remedies under section 502 (a) of the Act on the basis that the plan has failed to provide a reasonable claims procedure that would yield a decision on the merits of the claim. If a claimant chooses to pursue remedies under section 502 (a) of the Act under such circumstances, the claim or appeal is deemed denied on review without the exercise of discretion by an appropriate fiduciary.
What is a claim for benefits?
For purposes of this section, a claim for benefits is a request for a plan benefit or benefits made by a claimant in accordance with a plan's reasonable procedure for filing benefit claims. In the case of a group health plan, a claim for benefits includes any pre-service claims within the meaning of paragraph (m) ...
How long does a health insurance extension last?
If the plan administrator determines that an extension of time for processing is required, written notice of the extension shall be furnished to the claimant prior to the termination of the initial 60-day period. In no event shall such extension exceed a period of 60 days from the end of the initial period.
What is the ruling in Penn Chiropractic v. BCBSA?
The ruling in Penn. Chiropractic Ass’n v. BCBSA threatens to make recoveries more difficult for all insurers and may complicate the claims administration of self-funded plans. It also may necessitate self-insured plan sponsors reviewing network contracts with providers.
Why did the defendants argue that the providers lacked standing to sue?
The defendants argued that the providers lacked standing to sue because only participants and beneficiaries have the right to sue to recover ERISA benefits. The question of whether PCA members could sue hinged on whether they were beneficiaries
What is the case of Penn Chiropractic v. Blue Cross Blue Shield?
In the latest ruling, Penn. Chiropractic Assn. v. the Blue Cross Blue Shield Assn ., 09-cv-05619 (N.D. Ill., March 29, 2014), PCA asked the court to order IBC to reform its policies of recovering overpayments from chiropractors. PCA members testified that IBC used an improper notice and appeal process. They also said they were entitled to ERISA’s notice and appeal rights.
Challenging the Denial of an Employee Benefit Claim
If your initial claim is denied, ERISA's detailed regulations require that the insurer or plan provide a fair and transparent appeal process, within specific timeframes. An appeal must be done before initiating litigation, or the court will not hear your case.
Crucial Deadlines for an ERISA Appeal
As the claimant, you typically have 180 days from the date of the denial to appeal the decision, however, a statute of limitations for filing a lawsuit may be shorter and run separately from the appeal timeline. It is therefore critical to consult an attorney soon after your claim is denied.
The Importance of the Administrative Record in the ERISA Appeal Process
If your appeal is denied by the plan and your case is strong enough to warrant filing a lawsuit, your case will be reviewed by a judge, typically through a motion that provides the court with the record put together during the appeal process, called the administrative record.