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Timing Requirements for Appeals


The time period for calculating
The time for making an initial claims decision begins to run when the claim is filed in accordance with a plan's reasonable filing procedures, regardless of whether the plan has all of the information necessary to decide the claim at the time of the filing.

 

For purposes of calculating the time period within which a claim must be decided, a plan cannot extend the time period by treating as filed only those claims with respect to which all the information necessary to make a decision has been submitted often referred to as clean claims.   (More information can be found on the sidebar under type of claim.)

 

Timeframes for Deciding Appeals

Type of Appeal Benefit Determination on Review

Urgent Care

ASAP ≤ 72 hours-no extensions

Pre-Service

Reasonable period ≤ 30 days-no extensions

Post-Service

Reasonable period ≤ 60 days- no extensions

Disability

Reasonable period ≤ 45 days

45 day extension with notice

All other Appeals

Reasonable period ≤ 60 days

60 day extension with notice

Concurrent Care Decision*

When plan reverses pre-approval, before treatment ends or is reduced

* Concurrent care claims/decision

 

Concurrent claims are claims where a reduction or termination of benefits during the course of treatment [except for when a plan is amended] results in a claim not being paid at the same level. These types of claims are treated as an adverse determination under regulations. The plan administrator is required to prove the claimant sufficient advance notice of the reduction or termination to allow the claimant to appeal and obtain a determination before the benefit is reduced or terminated.

 

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.