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Claims Procedures Regulations


The DOL claims procedure regulations impose different deadlines, depending on the type of claim and paperwork item involved.

 

The following table summarizes the applicable deadline.

 

At a Glance: Group Health Claim and Appeal Processing Deadlines

 

 

Urgent Care ClaimPre-Service ClaimPost-Service ClaimConcurrent Care
Notification of Initial Claim Approval ASAP
<=72 hours
Reasonable period
<=15 days
Not required Same as urgent care or pre-service, as applicable, where claim is request for extension of concurrent care
Notification of Initial Adverse Benefit Determination ASAP
<=72 hours*

Reasonable period
<=15 days

 

15-day extension with notice

Reasonable period
<=30 days

 

15-day extension with notice

ASAP <=24 hours, where claim is request for urgent extension of concurrent care and request is made within 24 hours of end of period or number of treatments; otherwise, normal periods apply
Notice of Extension of Initial Determination Period No extension permitted

Up to one 15-day extension for “matters beyond control of plan”

 

Period tolled for incomplete claim (claimant must have 45 days to complete)

 

15 days to decide from provision of information

Up to one 15-day extension for “matters beyond control of plan”

 

Period tolled for incomplete claim (claimant must have 45 days to complete)

 

15 days to decide from provision of information

Same as pre-service, where claim is request for extension of concurrent care but no extension where urgent care involved
Notification of Benefit Determination on Review (adverse or not)

ASAP

<=72 hours

 

No extensions

Reasonable period
<=30 days

 


No extensions

Reasonable period
<=60 days

 

No extensions

 

Special rule for multiemployer plans

Before treatment ends or is reduced, where adverse benefit determination is plan decision to reduce or terminate concurrent care early
Incorrectly Filed Claim Notice ASAP
<=24 hours
ASAP
<=5 days
Not required Same as urgent care or pre-service, as applicable, where claim is request for extension of concurrent care

 

* Appeals regulations issued under health care reform initially provided for a 24-hour deadline for responding to urgent care claims; the amended appeals regulations did not retain this requirement.

 

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.