Introduction
This booklet will explain to people who participate in workplace-provided health benefit plans some of the obligations of those plans and outline the procedures and time limits for filing a medical claim.
The Employee Retirement Income Security Act of 1974 ( ERISA ) protects your health care benefits and sets standards for plan administrators. The law and related rules include, but are not limited to:
- Requirements for processing benefit claims,
- the time frame for making a decision, and
- Your rights if your claim is denied.
The medical claims rules discussed in this booklet generally apply to people who receive medical benefits from private industry employee plans. There are exceptions to plans sponsored by the government or most religious groups.
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If you are not sure whether ERISA laws apply to your situation, contact your plan administrator for more information.
Review your plan’s information
When you first join your employer’s plan, you’ll receive a document called a Summary Plan Description ( SPD ). This document details how the plan will work, what benefits are offered, how to file a claim for benefits, and any applicable limitations; it also explains your rights and responsibilities under ERISA and the plan rules. You can also find answers to many of your questions in the Summary of Benefits and Coverage ( SBC ). The SBC is a short, easy-to-understand document that contains detailed information about the benefits your plan offers and your out-of-pocket costs for coverage. If you are in a single-employer collectively bargained plan, the procedures for filing claims, disputes, and grievances may also be affected by the collective bargaining agreement.
Before you apply for benefits, review the Summary Plan Statement to make sure you meet the plan’s requirements and understand the procedures for making a claim. The procedures for making a claim are sometimes in a separate booklet. If you do not have the Summary Plan Statement or the claims procedures material for the plan, contact your plan administrator, who must give you a copy. Keep a copy or similar document for your own reference.
Filing a claim
The first step in filing a claim is to review your plan’s Summary Statement of Plans and Summary of Benefits and Coverage to make sure you meet the plan’s requirements to receive benefits. For example, your plan may require you to go through a waiting period before you can join the plan and receive benefits, or that dependents become ineligible for coverage after a certain age. Also, pay attention to your plan’s rules for filing claims. The information your Summary Statement of Plans or claims procedures booklet must provide includes where to file a claim, what to file a claim for, and how to contact your plan counselor. If the booklet does not have this information, contact your plan administrator, your employer’s human resources department (or the office that normally handles claims), or your employer and let them know you have a claim. Keep a copy of the letter for your records. It is recommended that you send it by certified mail, return receipt requested, so you have a record of who received it.
If the claim is filed by an authorized representative on your behalf, the plan rules may require you to complete a form designating that representative. The authorized representative must follow the plan’s claim procedures in the Summary of Plan Description. If the claim involves an emergency medical treatment, your primary care physician may automatically be your authorized representative without you having to complete a form.
When you file a claim, be sure to keep a copy for your records. Note that plans generally cannot charge any fees for filing and appealing a claim.
Types of claims
There are three types of medical claims – emergency medical, pre-service and post-service.
An emergency medical claim is a special type of pre-service claim that requires a quicker decision because waiting for the normal pre-service claim process puts your health at risk. If a doctor who knows your medical condition tells the plan administrator that the pre-service claim is an emergency, the plan must treat it as an emergency medical claim.
Pre-service claims are approvals required prior to medical treatment, such as seeking prior approval for treatment and determining whether a treatment or medical procedure is medically necessary.
Post-service claims are all other claims for benefits under your group health plan, including claims after health care services are provided, such as requests for reimbursement or payment for services provided. Most claims for group health benefits are post-service claims.
Awaiting decision on claim
ERISA specifies the timeframe within which a plan should evaluate your claim and notify you of its decision, measured in calendar days, so weekends and holidays are included. A plan must pay or provide benefits within a reasonable time after a claim is approved, but ERISA does not set specific timeframes. Please review your Summary Plan Explanation to learn how and when benefits will be paid.
| Claim Type | Decision Deadline |
|---|---|
| Emergency Medical Treatment | As soon as possible, but no later than 72 hours after receipt of the claim |
| Before service | Within a reasonable time, but not later than 15 days * of receipt of the claim. |
| After service | Within a reasonable time, but not later than 30 days * of receipt of the claim. |
*Please note: In exceptional circumstances, programs may extend decision deadlines.
Decisions on emergency medical claims must be made as quickly as possible, taking into account the patient’s medical needs, but no later than 72 hours after the plan receives the claim .
If a plan needs more information, it must tell you within 24 hours and give you at least 48 hours to respond. The plan must make a decision on the claim within 48 hours of receiving the missing information or within 48 hours of the deadline for providing the missing information, whichever comes first. The plan cannot extend the deadline for making a preliminary decision without your consent. The plan must notify you whether the claim is approved before the required deadline. The plan may notify you verbally, but must provide written notice within three days of the verbal notice.
A plan must make a decision on a pre-service claim within a reasonable time appropriate to the medical circumstances , but no later than 15 days after the plan’s receipt of the claim .
If the plan cannot make a decision within the first 15 days for reasons beyond its control, the plan can extend that time by up to a further 15 days. If an extension is required, the plan must notify you before the end of the first 15 days of:
- Explain the reason for the delay,
- request any additional information from you, and
- Let you know when you can expect a decision.
If the plan asks for more information, you have at least 45 days to provide it. The plan must make a decision on the claim within 15 days of receiving the additional information or within 15 days of the deadline for providing the additional information, whichever comes first. The plan cannot extend the deadline without your consent. The plan must notify you in writing whether your claim is approved or denied by the decision deadline.
Plans must make decisions on post-service medical claims within a reasonable time , but no later than 30 days after the plan receives the claim .
If the plan is unable to make a decision within the first 30 days due to reasons beyond its control, the plan can extend that time by up to 15 days. However, the plan must notify you before the end of the first 30-day period of:
- Explain the reason for the delay,
- Request any additional information required from you, and
- Let you know when you can expect a decision.
If the plan asks for more information, you have at least 45 days to provide it. The plan must make a decision on the claim within 15 days of receiving the 3 supplement or within 15 days of the deadline to provide the supplement, whichever comes first. The plan cannot extend the deadline without your consent. The plan must give you notice before the decision deadline that your claim is being denied in whole or in part (paying less than 100% of the claim is a partial denial).
If your claim is denied, the plan administrator must send you a notice in writing or electronically. The notice must include the following:
- The specific reason for the denial (e.g., not medically necessary, not covered by the plan, or exceeds the maximum amount of treatment allowed by the plan);
- Identify the specific plan provisions upon which the denial was based;
- If the application is rejected due to lack of information, indicate any additional information that is required and explain why additional information is required;
- Describe the program’s review procedures (e.g., the appeals process and/or how to file an appeal);
- If the denial is based on a rule, guideline, or protocol, the rule, guideline, or protocol on which the claim was denied should be stated, or a copy of such item should be provided free of charge upon request;
- If the denial is based on medical necessity, experimental treatment, or a similar exclusion or limitation, an explanation of the scientific or clinical judgment underlying the denial in applying the plan terms to your condition, or a statement that the explanation will be provided free of charge upon request; and
- Explain your rights to seek recovery from court for benefits under the plan.
Appealing a Denied Claim
There are different reasons why a claim is denied. Maybe you didn’t qualify for benefits, maybe you received services that weren’t covered by your plan, or maybe the plan just needs more information about your claim. Whatever the reason, you have at least 180 days to file an appeal (check your Plan Summary Explanations or claims procedures to see if your plan has a longer time limit).
Use the information in your Notice of Denial when preparing your appeal. If you ask, the plan must give you copies of documents, records, and other information related to your claim, free of charge. You can also ask the plan to provide the identities of the medical or vocational experts it sought opinions from. Be sure to include all the information related to your claim in your appeal, especially any additional information or evidence you want the plan to consider, and give it to the person named in the Notice of Denial before the end of the 180-day period.
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Appeal Review
When you appeal, your claim must be reviewed by a new person who will review all submitted information. If medical judgment is involved, this person will consult with qualified medical experts. This person cannot be the person who made the original decision, nor can they be someone who reports to them, and this person cannot take the original decision into account.
The time frame within which the program reviews your appeal varies depending on the type of claim you file.
| Claim Type | Deadline for appeal review |
|---|---|
| Emergency Medical Treatment | As soon as possible, taking into account your medical needs, but no later than 72 hours after receiving the request to review the denied claim |
| Before service | Within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days after receipt of the request to review a denied claim * |
| After service | Within a reasonable period of time, but not more than 60 days * after receipt of the request for review of the denied claim. |
*Please note: The Plan may extend the time limit for appeal review if the claimant agrees.
The plan cannot extend the deadline without your consent. There are two exceptions to these time limits.
- A single-employer collective bargaining plan generally may use the collectively bargained dispute procedures as its claims appeal procedures, provided that the procedures contain provisions for the filing, determination, and consideration of benefit claims.
- Multiemployer collective bargaining plans have specific time limits that allow them to schedule consideration of post-service claims at quarterly meetings of the Board of Trustees.
If you are a participant in one of these plans and have questions about your plan’s rules, you can review your plan’s Summary Plan Statement and collective bargaining agreement or contact the Department of Labor’s Employee Benefits Security Administration ( EBSA ) at 1-866-444-3272 .
A plan may require two levels of review of a denied medical claim to complete the plan’s claims process. In such cases, the maximum time for each review is generally half the time allowed for a single review. For example, a group health plan with a single level of appeal must review a pre-service claim within a reasonable time appropriate to the medical circumstances, but no later than 30 days after the plan receives your appeal. If the plan provides for two levels of appeals, each review must be completed within 15 days of the date the pre-service claim appeal was filed. If your appeal is denied after the first review, the plan must give you a reasonable amount of time (but not necessarily 180 days) to request a second review.
If the plan makes a final decision on your claim, the plan must give you a written explanation of the decision, including the following:
- The specific reasons for rejecting the claim;
- Indicate the provisions of the plan on which the decision is based;
- A description of any voluntary procedures established by the plan for resolving claims disputes;
- Explain that you have a right to receive, free of charge, documents related to your claim for benefits (papers and records on which the decision was based, and other documents prepared or used in the process); and
- Explain your rights to seek judicial review of a plan’s decisions.
Additional Rules for Plans Not Covered by the Affordable Care Act
The act imposes additional requirements on claims processing for group health plans that are not “excluded from the ACA.” Excluded plans are those that were established after March 23, 2010, or that made certain significant changes after March 23, 2010. Claims and appeal procedures must include revocation of coverage (retroactive cancellations), and other denials of benefits. The plan or its insurer must:
- Provide you with new or additional evidence or arguments and give you a reasonable opportunity to respond to them before making a final decision on your claim;
- ensuring independent and impartial decisions on claims and appeals;
- Provide in all claim denial notices a detailed description of the reasons why the claim was denied (including the denial code and its meaning), any available internal and external appeals procedures, and consumer assistance information;
- Provide upon request the diagnosis and treatment codes (and their meanings) for any denied claims;
- Providing notifications in a culturally and linguistically appropriate manner;
- Allows you to initiate an external review process if a plan does not comply with internal claims requirements (unless the plan’s noncompliance is minimal); and
- If the external examiner denies your request for an immediate external review under certain circumstances, you are permitted to resubmit your claim through the internal claims process.
In addition, plans that are not “outside the ACA” must have provisions for external reviews of claim denial decisions by an independent party. The external review procedures a plan uses depend on whether the plan provides benefits out of pocket or through an insurance company. The claim denial notice from your plan will describe the external procedures and your rights. If you want to request an external review, follow the steps provided in the denial notice.
If your medical benefits appeal is denied
If the plan ultimately decides to deny your claim, you can seek legal advice to understand your rights to challenge the denial in court. Generally, you must complete the plan’s claims process before you can challenge a claim denial in court.
However, if you believe your plan does not have a claims procedure that complies with the Department of Labor’s rules, or is not following that procedure, you can seek legal advice to learn about your rights to have your benefit claim heard in court without waiting for the plan’s decision. You can also contact a nearby EBSA office to learn about your rights if you believe your plan is not following ERISA in handling your benefit claim .
Filing a claim – Summary
- Before you file a claim, review the plan’s benefits and claims procedures. Read your Plan Summary Explanation and Summary of Benefits and Coverage. If you have questions, contact your plan administrator.
- After your claim is filed, decision timelines vary, depending on the type of claim, from 72 hours to 30 days. Your plan can extend certain timelines, but it must notify you before doing so. You will usually receive a decision within that timeline.
- If your claim is denied, the plan must send you a written notice that includes specific information about why your claim was denied and how to appeal.
- You have at least 180 days to request a full and fair review of your denied claim. You should use the plan’s appeals procedures. Please note that you may need to collect and submit new evidence or information to help the plan review your claim.
- It may take 72 hours to 60 days to review your appeal, depending on the type of claim; the plan needs your consent for any extension. The plan must send you written notice telling you whether your appeal is approved or denied.
- If the appeal is denied, the written notice must tell you the reasons for the denial and state whether there are additional levels of appeal or if the plan has a voluntary appeals procedure, and should include a statement of your rights to seek judicial review of the plan’s decision.
- If your appeal is denied and your plan is not “excluded from the ACA,” the denial notice should explain your right to request an independent, outside review of your denied claim. To request an outside review, follow the steps provided in the notice.
- If your claim is denied, or if the plan fails to establish a reasonable claims procedure or fails to follow that procedure, you can seek legal advice. If you believe the plan is not following ERISA requirements, you can contact EBSA to discuss this.