Claims and Appeals
The Employee Retirement Income Security Act of 1974 (ERISA) requires certain conditions to be met when processing claims and appeals. The Department of Labor outlines specific requirements surrounding the content of notices of adverse benefit determinations as well as the timeline for making determinations for claims and appeals.
1.Claims - Health plans and insurers are required to implement claims procedures and document those procedures within each client's plan document or contract. The DOL claims procedure regulations impose different deadlines, depending on the type of claim (urgent care claim, pre-service claim, post service claim).
2.Appeals - Health plans and insurers are required to implement internal appeal procedures and document those procedures within each client's plan document or contract. If the claim is denied or the member's health insurance coverage cancelled, plan participants have the right to an internal appeal. Plan participants may ask the plan or carrier to conduct a full and fair review of its decision. If the case is urgent, the timeline for completion of the internal appeal is expedited.
3.External Review - A member has the right to take the appeal to an independent third party for review. This is called external review. External review means that the insurance company no longer gets the final say over whether to pay a claim.
4.Legal Alternatives - ERISA claimants must generally "exhaust" the procedures before bringing a lawsuit against the plan. (Although, under health care reform, a claimant may be deemed to have exhausted a plan's internal claims and appeals procedures, if the plan or insurer does not strictly comply with those procedures).
For more information:
- Claims Procedures
- Claims Procedures Regulations
- Urgent Care Claims
- Pre-Service Claims
- Post Service Claims
- Timing Requirements for Appeals
- Disability Claims
- Internal Appeals
- External Appeals
This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.