29 CFR 2560.503-1 - Claims procedure.
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Section Number: 2560.503-1
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Section Name: Claims procedure.
(a) Scope and purpose. In accordance with the authority of
sections
503
and 505 of the Employee Retirement Income Security Act of
1974
(ERISA or the Act), 29 U.S.C. 1133, 1135, this section sets
forth
minimum requirements for employee benefit plan procedures
pertaining to
claims for benefits by participants and beneficiaries
(hereinafter
referred to as claimants). Except as otherwise specifically
provided in
this
section, these requirements apply to every employee benefit
plan
described in section 4(a) and not exempted under section
4(b) of the
Act.
(b) Obligation to establish and maintain reasonable claims
procedures.
Every
employee benefit plan shall establish and maintain
reasonable
procedures governing the filing of benefit claims,
notification of
benefit determinations, and appeal of adverse benefit
determinations
(hereinafter collectively referred to as claims procedures).
The claims
procedures for a plan will be deemed to be reasonable only
if--
(1) The claims procedures comply with the requirements of
paragraphs (c), (d), (e), (f), (g), (h), (i), and (j) of
this section,
as
appropriate, except to the extent that the claims procedures
are
deemed to comply with some or all of such provisions
pursuant to
paragraph (b)(6) of this section;
(2) A description of all claims procedures (including, in
the case
of a
group health plan within the meaning of paragraph (m)(6) of
this
section, any procedures for obtaining prior approval as a
prerequisite
for
obtaining a benefit, such as preauthorization procedures or
utilization review procedures) and the applicable time
frames is
included as part of a summary plan description meeting the
requirements
of 29
CFR 2520.102-3;
(3) The claims procedures do not contain any provision, and
are not
administered in a way, that unduly inhibits or hampers the
initiation
or
processing of claims for benefits. For example, a provision
or
practice that requires payment of a fee or costs as a
condition to
making a claim or to appealing an adverse benefit
determination would
be
considered to unduly inhibit the initiation and processing
of claims
for
benefits. Also, the denial of a claim for failure to obtain
a prior
approval under circumstances that would make obtaining such
prior
approval impossible or where application of the prior
approval process
could
seriously jeopardize the life or health of the claimant
(e.g., in
the
case of a group health plan, the claimant is unconscious and
in
need
of immediate care at the time medical treatment is required)
would
constitute a practice that unduly inhibits the initiation
and
processing of a claim;
(4) The claims procedures do not preclude an authorized
representative of a claimant from acting on behalf of such
claimant in
pursuing a benefit claim or appeal of an adverse benefit
determination.
Nevertheless, a plan may establish reasonable procedures for
determining whether an individual has been authorized to act
on behalf
of a
claimant, provided that, in the case of a claim involving
urgent
care,
within the meaning of paragraph (m)(1) of this section, a
health
care
professional, within the meaning of paragraph (m)(7) of this
section, with knowledge of a claimant's medical condition
shall be
permitted to act as the authorized representative of the
claimant; and
(5) The claims procedures contain administrative processes
and
safeguards designed to ensure and to verify that benefit
claim
determinations are made in accordance with governing plan
documents and
that,
where appropriate, the plan provisions have been applied
consistently with respect to similarly situated claimants.
(6) In the case of a plan established and maintained
pursuant to a
collective bargaining agreement (other than a plan subject
to the
provisions of section 302(c)(5) of the Labor Management
Relations Act,
1947
concerning joint representation on the board of trustees)--
(i)
Such plan will be deemed to comply with the provisions of
paragraphs (c) through (j) of this section if the collective
bargaining
agreement pursuant to which the plan is established or
maintained sets
forth
or incorporates by specific reference--
(A) Provisions concerning the filing of benefit claims and
the
initial disposition of benefit claims, and
(B) A grievance and arbitration procedure to which adverse
benefit
determinations are subject.
(ii) Such plan will be deemed to comply with the provisions
of
paragraphs (h), (i), and (j) of this section (but will not
be deemed to
comply with paragraphs (c) through (g) of this section) if
the
collective bargaining agreement pursuant to which the plan
is
established or maintained sets forth or incorporates by
specific
reference a grievance and arbitration procedure to which
adverse
benefit determinations are subject (but not provisions
concerning the
filing and initial disposition of benefit claims).
(c) Group health plans. The claims procedures of a group
health
plan
will be deemed to be reasonable only if, in addition to
complying
with
the requirements of paragraph (b) of this section--
(1)(i) The claims procedures provide that, in the case of a
failure
by a
claimant or an authorized representative of a claimant to
follow
the
plan's procedures for filing a pre-service claim, within the
meaning of paragraph (m)(2) of this section, the claimant or
representative shall be notified of the failure and the
proper
procedures to be followed in filing a claim for benefits.
This
notification shall be provided to the claimant or authorized
representative, as appropriate, as soon as possible, but not
later than
5
days (24 hours in the case of a failure to file a claim
involving
urgent care) following the failure. Notification may be
oral, unless
written notification is requested by the claimant or
authorized
representative.
(ii) Paragraph (c)(1)(i) of this section shall apply only in
the
case
of a failure that--
(A) Is a communication by a claimant or an authorized
representative of a claimant that is received by a person or
organizational unit customarily responsible for handling
benefit
matters; and
(B) Is a communication that names a specific claimant; a
specific
medical condition or symptom; and a specific treatment,
service, or
product for which approval is requested.
(2) The claims procedures do not contain any provision, and
are not
administered in a way, that requires a claimant to file more
than two
appeals of an adverse benefit determination prior to
bringing a civil
action under section 502(a) of the Act;
(3) To the extent that a plan offers voluntary levels of
appeal
(except to the extent that the plan is required to do so by
State law),
including voluntary arbitration or any other form of dispute
resolution, in addition to those permitted by paragraph
(c)(2) of this
section, the claims procedures provide that:
(i)
The plan waives any right to assert that a claimant has
failed
to
exhaust administrative remedies because the claimant did not
elect
to
submit a benefit dispute to any such voluntary level of
appeal
provided by the plan;
(ii) The plan agrees that any statute of limitations or
other
defense based on timeliness is tolled during the time that
any such
voluntary appeal is pending;
(iii) The claims procedures provide that a claimant may
elect to
submit a benefit dispute to such voluntary level of appeal
only after
exhaustion of the appeals permitted by paragraph (c)(2) of
this
section;
(iv) The plan provides to any claimant, upon request,
sufficient
information relating to the voluntary level of appeal to
enable the
claimant to make an informed judgment about whether to
submit a benefit
dispute to the voluntary level of appeal, including a
statement that
the
decision of a claimant as to whether or not to submit a
benefit
dispute to the voluntary level of appeal will have no effect
on the
claimant's rights to any other benefits under the plan and
information
about
the applicable rules, the claimant's right to
representation, the
process for selecting the decisionmaker, and the
circumstances, if any,
that
may affect the impartiality of the decisionmaker,
such
as any financial or personal interests in the result or any
past
or
present relationship with any party to the review process;
and
(v) No fees or costs are imposed on the claimant as part of
the
voluntary level of appeal.
(4) The claims procedures do not contain any provision for
the
mandatory arbitration of adverse benefit determinations,
except to the
extent that the plan or procedures provide that:
(i)
The arbitration is conducted as one of the two appeals
described in paragraph (c)(2) of this section and in
accordance with
the
requirements applicable to such appeals; and
(ii) The claimant is not precluded from challenging the
decision
under
section 502(a) of the Act or other applicable law.
(d) Plans providing disability benefits. The claims
procedures of a
plan
that provides disability benefits will be deemed to be
reasonable
only
if the claims procedures comply, with respect to claims for
disability benefits, with the requirements of paragraphs
(b), (c)(2),
(c)(3), and (c)(4) of this section.
(e) 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)(2)
of
this section and any post-service claims within the meaning
of
paragraph (m)(3) of this section.
(f) Timing of notification of benefit determination. (1) In
general. Except as provided in paragraphs (f)(2) and (f)(3)
of this
section, if a claim is wholly or partially denied, the plan
administrator shall notify the claimant, in accordance with
paragraph
(g)
of this section, of the plan's adverse benefit determination
within
a
reasonable period of time, but not later than 90 days after
receipt
of
the claim by the plan, unless the plan administrator
determines that
special circumstances require an extension of time for
processing the
claim. 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 90-
day
period. In no event shall such extension exceed a period of
90 days
from
the end of such initial period. The extension notice shall
indicate the special circumstances requiring an extension of
time and
the
date by which the plan expects to render the benefit
determination.
(2) Group health plans. In the case of a group health plan,
the
plan
administrator shall notify a claimant of the plan's benefit
determination in accordance with paragraph (f)(2)(i),
(f)(2)(ii), or
(f)(2)(iii) of this section, as appropriate.
(i)
Urgent care claims. In the case of a claim involving urgent
care,
the plan administrator shall notify the claimant of the
plan's
benefit determination (whether adverse or not) as soon as
possible,
taking into account the medical exigencies, but not later
than 72 hours
after
receipt of the claim by the plan, unless the claimant fails
to
provide sufficient information to determine whether, or to
what extent,
benefits are covered or payable under the plan. In the case
of such a
failure, the plan administrator shall notify the claimant as
soon as
possible, but not later than 24 hours after receipt of the
claim by the
plan,
of the specific information necessary to complete the claim.
The
claimant shall be afforded a reasonable amount of time,
taking into
account the circumstances, but not less than 48 hours, to
provide the
specified information. Notification of any adverse benefit
determination pursuant to this paragraph (f)(2)(i) shall be
made in
accordance with paragraph (g) of this section. The plan
administrator
shall
notify the claimant of the plan's benefit determination as
soon
as
possible, but in no case later than 48 hours after the
earlier of--
(A) The plan's receipt of the specified information, or
(B) The end of the period afforded the claimant to provide
the
specified additional information.
(ii) Concurrent care decisions. If a group health plan has
approved
an
ongoing course of treatment to be provided over a period of
time or
number of treatments--
(A) Any reduction or termination by the plan of such course
of
treatment (other than by plan amendment or termination)
before the end
of
such period of time or number of treatments shall constitute
an
adverse benefit determination. The plan administrator shall
notify the
claimant, in accordance with paragraph (g) of this section,
of the
adverse benefit determination at a time sufficiently in
advance of the
reduction or termination to allow the claimant to appeal and
obtain a
determination on review of that adverse benefit
determination before
the
benefit is reduced or terminated.
(B) Any request by a claimant to extend the course of
treatment
beyond the period of time or number of treatments that is a
claim
involving urgent care shall be decided as soon as possible,
taking into
account the medical exigencies, and the plan administrator
shall notify
the
claimant of the benefit determination, whether adverse or
not,
within 24 hours after receipt of the claim by the plan,
provided that
any
such claim is made to the plan at least 24 hours prior to
the
expiration of the prescribed period of time or number of
treatments.
Notification of any adverse benefit determination concerning
a request
to
extend the course of treatment, whether involving urgent
care or
not,
shall be made in accordance with paragraph (g) of this
section,
and
appeal shall be governed by paragraph (i)(2)(i), (i)(2)(ii),
or
(i)(2)(iii),
as appropriate.
(iii) Other claims. In the case of a claim not described in
paragraphs (f)(2)(i) or (f)(2)(ii) of this section, the plan
administrator shall notify the claimant of the plan's
benefit
determination in accordance with either paragraph (f)(2)(iii)(A)
or
(f)(2)(iii)(B) of this section, as appropriate.
(A) Pre-service claims. In the case of a pre-service claim,
the
plan
administrator shall notify the claimant of the plan's
benefit
determination (whether adverse or not) within a reasonable
period of
time
appropriate to the medical circumstances, but not later than
15
days
after receipt of the claim by the plan. This period may be
extended one time by the plan for up to 15 days, provided
that the plan
administrator both determines that such an extension is
necessary due
to
matters beyond the control of the plan and notifies the
claimant,
prior
to the expiration of the initial 15-day period, of the
circumstances requiring the extension of time and the date
by which the
plan
expects to render a decision. If such an extension is
necessary
due
to a failure of the claimant to submit the information
necessary to
decide the claim, the notice of extension shall specifically
describe
the
required information, and the claimant shall be afforded at
least
45
days from receipt of the notice within which to provide the
specified information. Notification of any adverse benefit
determination pursuant to this paragraph (f)(2)(iii)(A)
shall be made
in
accordance with paragraph (g) of this section.
(B) Post-service claims. In the case of a post-service
claim, the
plan
administrator shall notify the claimant, in accordance with
paragraph (g) of this section, of the plan's adverse benefit
determination within a reasonable period of time, but not
later than 30
days
after receipt of the claim. This period may be extended one
time
by
the plan for up to 15 days, provided that the plan
administrator
both
determines that
such
an extension is necessary due to matters beyond the control
of the
plan
and notifies the claimant, prior to the expiration of the
initial
30-day period, of the circumstances requiring the extension
of time and
the
date by which the plan expects to render a decision. If such
an
extension is necessary due to a failure of the claimant to
submit the
information necessary to decide the claim, the notice of
extension
shall
specifically describe the required information, and the
claimant
shall
be afforded at least 45 days from receipt of the notice
within
which
to provide the specified information.
(3) Disability claims. In the case of a claim for disability
benefits, the plan administrator shall notify the claimant,
in
accordance with paragraph (g) of this section, of the plan's
adverse
benefit determination within a reasonable period of time,
but not later
than
45 days after receipt of the claim by the plan. This period
may be
extended by the plan for up to 30 days, provided that the
plan
administrator both determines that such an extension is
necessary due
to
matters beyond the control of the plan and notifies the
claimant,
prior
to the expiration of the initial 45-day period, of the
circumstances requiring the extension of time and the date
by which the
plan
expects to render a decision. If, prior to the end of the
first
30-day extension period, the administrator determines that,
due to
matters beyond the control of the plan, a decision cannot be
rendered
within that extension period, the period for making the
determination
may
be extended for up to an additional 30 days, provided that
the plan
administrator notifies the claimant, prior to the expiration
of the
first
30-day extension period, of the circumstances requiring the
extension and the date as of which the plan expects to
render a
decision. In the case of any extension under this paragraph
(f)(3), the
notice of extension shall specifically explain the standards
on which
entitlement to a benefit is based, the unresolved issues
that prevent a
decision on the claim, and the additional information needed
to resolve
those
issues, and the claimant shall be afforded at least 45 days
within which to provide the specified information.
(4) Calculating time periods. For purposes of paragraph (f)
of this
section, the period of time within which a benefit
determination is
required to be made shall begin at the time a claim is filed
in
accordance with the reasonable procedures of a plan, without
regard to
whether all the information necessary to make a benefit
determination
accompanies the filing. In the event that a period of time
is extended
as
permitted pursuant to paragraph (f)(2)(iii) or (f)(3) of
this
section due to a claimant's failure to submit information
necessary to
decide a claim, the period for making the benefit
determination shall
be
tolled from the date on which the notification of the
extension is
sent
to the claimant until the date on which the claimant
responds to
the
request for additional information.
(g) Manner and content of notification of benefit
determination.
(1)
Except as provided in paragraph (g)(2) of this section, the
plan
administrator shall provide a claimant with written or
electronic
notification of any adverse benefit determination. Any
electronic
notification shall comply with the standards imposed by 29
CFR
2520.104b-1(c)(1)(i), (iii), and (iv). The notification
shall set
forth, in a manner calculated to be understood by the
claimant --
(i)
The specific reason or reasons for the adverse
determination;
(ii) Reference to the specific plan provisions on which the
determination is based;
(iii) A description of any additional material or
information
necessary for the claimant to perfect the claim and an
explanation of
why
such material or information is necessary;
(iv) A description of the plan's review procedures and the
time
limits applicable to such procedures, including a statement
of the
claimant's right to bring a civil action under section
502(a) of the
Act
following an adverse benefit determination on review;
(v) In the case of an adverse benefit determination by a
group
health plan or a plan providing disability benefits,
(A) If an internal rule, guideline, protocol, or other
similar
criterion was relied upon in making the adverse
determination, either
the
specific rule, guideline, protocol, or other similar
criterion; or
a
statement that such a rule, guideline, protocol, or other
similar
criterion was relied upon in making the adverse
determination and that
a
copy of such rule, guideline, protocol, or other criterion
will be
provided free of charge to the claimant upon request; or
(B) If the adverse benefit determination is based on a
medical
necessity or experimental treatment or similar exclusion or
limit,
either an explanation of the scientific or clinical judgment
for the
determination, applying the terms of the plan to the
claimant's medical
circumstances, or a statement that such explanation will be
provided
free
of charge upon request.
(vi) In the case of an adverse benefit determination by a
group
health plan concerning a claim involving urgent care, a
description of
the
expedited review process applicable to such claims.
(2) In the case of an adverse benefit determination by a
group
health plan concerning a claim involving urgent care, the
information
described in paragraph (g)(1) of this section may be
provided to the
claimant orally within the time frame prescribed in
paragraph (f)(2)(i)
of
this section, provided that a written or electronic
notification in
accordance with paragraph (g)(1) of this section is
furnished to the
claimant not later than 3 days after the oral notification.
(h) Appeal of adverse benefit determinations. (1) In
general. Every
employee benefit plan shall establish and maintain a
procedure by which
a
claimant shall have a reasonable opportunity to appeal an
adverse
benefit determination to an appropriate named fiduciary of
the plan,
and
under which there will be a full and fair review of the
claim and
the
adverse benefit determination.
(2) Full and fair review. Except as provided in paragraphs
(h)(3)
and
(h)(4) of this section, the claims procedures of a plan will
not be
deemed to provide a claimant with a reasonable opportunity
for a full
and
fair review of a claim and adverse benefit determination
unless the
claims procedures--
(i)
Provide claimants at least 60 days following receipt of a
notification of an adverse benefit determination within
which to appeal
the
determination;
(ii) Provide claimants the opportunity to submit written
comments,
documents, records, and other information relating to the
claim for
benefits;
(iii) Provide that a claimant shall be provided, upon
request and
free
of charge, reasonable access to, and copies of, all
documents,
records, and other information relevant to the claimant's
claim for
benefits. Whether a document, record, or other information
is relevant
to a
claim for benefits shall be determined by reference to
paragraph
(m)(8) of this section;
(iv) Provide for a review that takes into account all
comments,
documents, records, and other information submitted by the
claimant
relating to the claim, without regard to whether such
information was
submitted or considered in the initial benefit
determination.
(3) Group health plans. The claims procedures of a group
health
plan
will not be deemed to provide a claimant with a reasonable
opportunity for a full
and
fair review of a claim and adverse benefit determination
unless, in
addition to complying with the requirements of paragraphs
(h)(2)(ii)
through (iv) of this section, the claims procedures--
(i)
Provide claimants at least 180 days following receipt of a
notification of an adverse benefit determination within
which to appeal
the
determination;
(ii) Provide for a review that does not afford deference to
the
initial adverse benefit determination and that is conducted
by an
appropriate named fiduciary of the plan who is neither the
individual
who
made the adverse benefit determination that is the subject
of the
appeal, nor the subordinate of such individual;
(iii) Provide that, in deciding an appeal of any adverse
benefit
determination that is based in whole or in part on a medical
judgment,
including determinations with regard to whether a particular
treatment,
drug,
or other item is experimental, investigational, or not
medically
necessary or appropriate, the appropriate named fiduciary
shall consult
with
a health care professional who has appropriate training and
experience in the field of medicine involved in the medical
judgment;
(iv) Provide for the identification of medical or vocational
experts whose advice was obtained on behalf of the plan in
connection
with
a claimant's adverse benefit determination, without regard
to
whether the advice was relied upon in making the benefit
determination;
(v) Provide that the health care professional engaged for
purposes
of a
consultation under paragraph (h)(3)(iii) of this section
shall be
an
individual who is neither an individual who was consulted in
connection with the adverse benefit determination that is
the subject
of
the appeal, nor the subordinate of any such individual; and
(vi) Provide, in the case of a claim involving urgent care,
for an
expedited review process pursuant to which--
(A) A request for an expedited appeal of an adverse benefit
determination may be submitted orally or in writing by the
claimant;
and
(B) All necessary information, including the plan's benefit
determination on review, shall be transmitted between the
plan and the
claimant by telephone, facsimile, or other available
similarly
expeditious method.
(4) Plans providing disability benefits. The claims
procedures of a
plan
providing disability benefits will not, with respect to
claims for
such
benefits, be deemed to provide a claimant with a reasonable
opportunity for a full and fair review of a claim and
adverse benefit
determination unless the claims procedures comply with the
requirements
of
paragraphs (h)(2)(ii) through (iv) and (h)(3)(i) through (v)
of this
section.
(i)
Timing of notification of benefit determination on review.
(1)
In
general. (i) Except as provided in paragraphs (i)(1)(ii), (i)(2),
and (i)(3)
of this section, the plan administrator shall notify a
claimant in accordance with paragraph (j) of this section of
the plan's
benefit determination on review within a reasonable period
of time, but
not
later than 60 days after receipt of the claimant's request
for
review by the plan, unless the plan administrator determines
that
special circumstances (such as the need to hold a hearing,
if the
plan's procedures provide for a hearing) require an
extension of time
for
processing the claim. 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. The
extension
notice shall indicate the special circumstances requiring an
extension
of
time and the date by which the plan expects to render the
determination on review.
(ii) In the case of a plan with a committee or board of
trustees
designated as the appropriate named fiduciary that holds
regularly
scheduled meetings at least quarterly, paragraph (i)(1)(i)
of this
section shall not apply, and, except as provided in
paragraphs (i)(2)
and (i)(3)
of this section, the appropriate named fiduciary shall
instead make a benefit determination no later than the date
of the
meeting of the committee or board that immediately follows
the plan's
receipt of a request for review, unless the request for
review is filed
within 30 days preceding the date of such meeting. In such
case, a
benefit determination may be made by no later than the date
of the
second meeting following the plan's receipt of the request
for review.
If
special circumstances (such as the need to hold a hearing,
if the
plan's procedures provide for a hearing) require a further
extension of
time
for processing, a benefit determination shall be rendered
not
later
than the third meeting of the committee or board following
the
plan's receipt of the request for review. If such an
extension of time
for
review is required because of special circumstances, the
plan
administrator shall provide the claimant with written notice
of the
extension, describing the special circumstances and the date
as of
which
the benefit determination will be made, prior to the
commencement
of
the extension. The plan administrator shall notify the
claimant, in
accordance with paragraph (j) of this section, of the
benefit
determination as soon as possible, but not later than 5 days
after the
benefit determination is made.
(2) Group health plans. In the case of a group health plan,
the
plan
administrator shall notify a claimant of the plan's benefit
determination on review in accordance with paragraphs (i)(2)(i)
through
(iii), as appropriate.
(i)
Urgent care claims. In the case of a claim involving urgent
care,
the plan administrator shall notify the claimant, in
accordance
with
paragraph (j) of this section, of the plan's benefit
determination
on
review as soon as possible, taking into account the medical
exigencies, but not later than 72 hours after receipt of the
claimant's
request for review of an adverse benefit determination by
the plan.
(ii) Pre-service claims. In the case of a pre-service claim,
the
plan
administrator shall notify the claimant, in accordance with
paragraph (j) of this section, of the plan's benefit
determination on
review within a reasonable period of time appropriate to the
medical
circumstances. In the case of a group health plan that
provides for one
appeal of an adverse benefit determination, such
notification shall be
provided not later than 30 days after receipt by the plan of
the
claimant's request for review of an adverse benefit
determination. In
the
case of a group health plan that provides for two appeals of
an
adverse determination, such notification shall be provided,
with
respect to any one of such two appeals, not later than 15
days after
receipt by the plan of the claimant's request for review of
the adverse
determination.
(iii) Post-service claims. (A) In the case of a post-service
claim,
except as provided in paragraph (i)(2)(iii)(B) of this
section, the
plan
administrator shall notify the claimant, in accordance with
paragraph (j) of this section, of the plan's benefit
determination on
review within a reasonable period of time. In the case of a
group
health plan that provides for one appeal of an adverse
benefit
determination, such notification shall be provided not later
than 60
days
after receipt by the plan of the claimant's request for
review of
an
adverse benefit determination. In the case of a group health
plan
that
provides for two appeals of an adverse determination, such
notification shall be provided, with respect to any one of
such
two appeals, not later than 30 days after receipt by the
plan of
the
claimant's request for review of the adverse determination.
(B) In the case of a multiemployer plan with a committee or
board
of
trustees designated as the appropriate named fiduciary that
holds
regularly scheduled meetings at least quarterly, paragraph
(i)(2)(iii)(A)
of this section shall not apply, and the appropriate
named
fiduciary shall instead make a benefit determination no
later
than
the date of the meeting of the committee or board that
immediately
follows the plan's receipt of a request for review, unless
the request
for
review is filed within 30 days preceding the date of such
meeting.
In
such case, a benefit determination may be made by no later
than the
date
of the second meeting following the plan's receipt of the
request
for
review. If special circumstances (such as the need to hold a
hearing, if the plan's procedures provide for a hearing)
require a
further extension of time for processing, a benefit
determination shall
be
rendered not later than the third meeting of the committee
or board
following the plan's receipt of the request for review. If
such an
extension of time for review is required because of special
circumstances, the plan administrator shall notify the
claimant in
writing of the extension, describing the special
circumstances and the
date
as of which the benefit determination will be made, prior to
the
commencement of the extension. The plan administrator shall
notify the
claimant, in accordance with paragraph (j) of this section,
of the
benefit determination as soon as possible, but not later
than 5 days
after
the benefit determination is made.
(3) Disability claims. (i) Except as provided in paragraph
(i)(3)(ii)
of this section, claims involving disability benefits
(whether the plan provides for one or two appeals) shall be
governed by
paragraph (i)(1) of this section, except that a period of
45 days shall
apply
instead of 60 days for purposes of that paragraph.
(ii) In the case of a multiemployer plan with a committee or
board
of
trustees designated as the appropriate named fiduciary that
holds
regularly scheduled meetings at least quarterly, paragraph (i)(3)(i)
of
this
section shall not apply, and the appropriate named fiduciary
shall
instead make a benefit determination no later than the date
of the
meeting of the committee or board that immediately follows
the plan's
receipt of a request for review, unless the request for
review is filed
within 30 days preceding the date of such meeting. In such
case, a
benefit determination may be made by no later than the date
of the
second meeting following the plan's receipt of the request
for review.
If
special circumstances (such as the need to hold a hearing,
if the
plan's procedures provide for a hearing) require a further
extension of
time
for processing, a benefit determination shall be rendered
not
later
than the third meeting of the committee or board following
the
plan's receipt of the request for review. If such an
extension of time
for
review is required because of special circumstances, the
plan
administrator shall notify the claimant in writing of the
extension,
describing the special circumstances and the date as of
which the
benefit determination will be made, prior to the
commencement of the
extension. The plan administrator shall notify the claimant,
in
accordance with paragraph (j) of this section, of the
benefit
determination as soon as possible, but not later than 5 days
after the
benefit determination is made.
(4) Calculating time periods. For purposes of paragraph (i)
of this
section, the period of time within which a benefit
determination on
review is required to be made shall begin at the time an
appeal is
filed
in accordance with the reasonable procedures of a plan,
without
regard to whether all the information necessary to make a
benefit
determination on review accompanies the filing. In the event
that a
period of time is extended as permitted pursuant to
paragraph (i)(1),
(i)(2)(iii)(B),
or (i)(3) of this section due to a claimant's failure
to
submit information necessary to decide a claim, the period
for
making the benefit determination on review shall be tolled
from the
date
on which the notification of the extension is sent to the
claimant
until
the date on which the claimant responds to the request for
additional information.
(5) Furnishing documents. In the case of an adverse benefit
determination on review, the plan administrator shall
provide such
access to, and copies of, documents, records, and other
information
described in paragraphs (j)(3), (j)(4), and (j)(5) of this
section as
is
appropriate.
(j) Manner and content of notification of benefit
determination on
review. The plan administrator shall provide a claimant with
written or
electronic notification of a plan's benefit determination on
review.
Any
electronic notification shall comply with the standards
imposed by
29
CFR 2520.104b-1(c)(1)(i), (iii), and (iv). In the case of an
adverse
benefit determination, the notification shall set forth, in
a manner
calculated to be understood by the claimant--
(1) The specific reason or reasons for the adverse
determination;
(2) Reference to the specific plan provisions on which the
benefit
determination is based;
(3) A statement that the claimant is entitled to receive,
upon
request and free of charge, reasonable access to, and copies
of, all
documents, records, and other information relevant to the
claimant's
claim
for benefits. Whether a document, record, or other
information is
relevant to a claim for benefits shall be determined by
reference to
paragraph (m)(8) of this section;
(4) A statement describing any voluntary appeal procedures
offered
by
the plan and the claimant's right to obtain the information
about
such
procedures described in paragraph (c)(3)(iv) of this
section, and
a
statement of the claimant's right to bring an action under
section
502(a) of the Act; and
(5) In the case of a group health plan or a plan providing
disability benefits--
(i)
If an internal rule, guideline, protocol, or other similar
criterion was relied upon in making the adverse
determination, either
the
specific rule, guideline, protocol, or other similar
criterion; or
a
statement that such rule, guideline, protocol, or other
similar
criterion was relied upon in making the adverse
determination and that
a
copy of the rule, guideline, protocol, or other similar
criterion
will
be provided free of charge to the claimant upon request;
(ii) If the adverse benefit determination is based on a
medical
necessity or experimental treatment or similar exclusion or
limit,
either an explanation of the scientific or clinical judgment
for the
determination, applying the terms of the plan to the
claimant's medical
circumstances, or a statement that such explanation will be
provided
free
of charge upon request; and
(iii) The following statement: ``You and your plan may have
other
voluntary alternative dispute resolution options, such as
mediation.
One
way to find out what may be available is to contact your
local U.S.
Department of Labor Office and your State insurance
regulatory
agency.''
(k) Preemption of State law. (1) Nothing in this section
shall be
construed to supersede any provision of State law that
regulates
insurance, except to the extent that such law prevents the
application
of a
requirement of this section.
(2) (i) For purposes of paragraph (k)(1) of this section, a
State
law
regulating insurance shall not be considered to prevent the
application of a requirement of this section merely because
such State
law
establishes a review procedure
to
evaluate and resolve disputes involving adverse benefit
determinations under group health plans so long as the
review procedure
is
conducted by a person or entity other than the insurer, the
plan,
plan
fiduciaries, the employer, or any employee or agent of any
of the
foregoing.
(ii) The State law procedures described in paragraph
(k)(2)(i) of
this
section are not part of the full and fair review required by
section 503 of the Act. Claimants therefore need not exhaust
such State
law
procedures prior to bringing suit under section 502(a) of
the Act.
(l) Failure to establish and follow reasonable claims
procedures.
In
the case of the failure of a plan to establish or follow
claims
procedures consistent with the requirements of this section,
a claimant
shall
be deemed to have exhausted the administrative remedies
available
under
the plan and shall be 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.
(m) Definitions. The following terms shall have the meaning
ascribed to such terms in this paragraph (m) whenever such
term is used
in
this section:
(1)(i) A ``claim involving urgent care'' is any claim for
medical
care
or treatment with respect to which the application of the
time
periods for making non-urgent care determinations--
(A) Could seriously jeopardize the life or health of the
claimant
or
the ability of the claimant to regain maximum function, or,
(B) In the opinion of a physician with knowledge of the
claimant's
medical condition, would subject the claimant to severe pain
that
cannot be adequately managed without the care or treatment
that is the
subject of the claim.
(ii) Except as provided in paragraph (m)(1)(iii) of this
section,
whether a claim is a ``claim involving urgent care'' within
the meaning
of
paragraph (m)(1)(i)(A) of this section is to be determined
by an
individual acting on behalf of the plan applying the
judgment of a
prudent layperson who possesses an average knowledge of
health and
medicine.
(iii) Any claim that a physician with knowledge of the
claimant's
medical condition determines is a ``claim involving urgent
care''
within the meaning of paragraph (m)(1)(i) of this section
shall be
treated as a ``claim involving urgent care'' for purposes of
this
section.
(2) The term ``pre-service claim'' means any claim for a
benefit
under
a group health plan with respect to which the terms of the
plan
condition receipt of the benefit, in whole or in part, on
approval of
the
benefit in advance of obtaining medical care.
(3) The term ``post-service claim'' means any claim for a
benefit
under
a group health plan that is not a pre-service claim within
the
meaning of paragraph (m)(2) of this section.
(4) The term ``adverse benefit determination'' means any of
the
following: a denial, reduction, or termination of, or a
failure to
provide or make payment (in whole or in part) for, a
benefit, including
any
such denial, reduction, termination, or failure to provide
or make
payment that is based on a determination of a participant's
or
beneficiary's eligibility to participate in a plan, and
including, with
respect to group health plans, a denial, reduction, or
termination of,
or a
failure to provide or make payment (in whole or in part)
for, a
benefit resulting from the application of any utilization
review, as
well
as a failure to cover an item or service for which benefits
are
otherwise provided because it is determined to be
experimental or
investigational or not medically necessary or appropriate.
(5) The term ``notice'' or ``notification'' means the
delivery or
furnishing of information to an individual in a manner that
satisfies
the
standards of 29 CFR 2520.104b-1(b) as appropriate with
respect to
material required to be furnished or made available to an
individual.
(6) The term ``group health plan'' means an employee welfare
benefit plan within the meaning of section 3(1) of the Act
to the
extent that such plan provides ``medical care'' within the
meaning of
section 733(a) of the Act.
(7) The term ``health care professional'' means a physician
or
other
health care professional licensed, accredited, or certified
to
perform specified health services consistent with State law.
(8) A document, record, or other information shall be
considered
``relevant'' to a claimant's claim if such document, record,
or other
information
(i)
Was relied upon in making the benefit determination;
(ii) Was submitted, considered, or generated in the course
of
making the benefit determination, without regard to whether
such
document, record, or other information was relied upon in
making the
benefit determination;
(iii) Demonstrates compliance with the administrative
processes and
safeguards required pursuant to paragraph (b)(5) of this
section in
making the benefit determination; or
(iv)
In the case of a group health plan or a plan providing
disability benefits, constitutes a statement of policy or
guidance with
respect
to the plan concerning the denied treatment option or benefit
for the
claimant's diagnosis, without regard to whether such advice or
statement
was relied upon in making the benefit determination.
(n)
Apprenticeship plans. This section does not apply to employee
benefit
plans that solely provide apprenticeship training benefits.
(o)
Applicability dates.
(1)
Except as provided in paragraph (o)(2) of this section, this
section
shall apply to claims filed under a plan on or after January 1,
2002.
(2)
This section shall apply to claims filed under a group health
plan on
or after the first day of the first plan year beginning on or
after
July 1, 2002, but in no event later than January 1, 2003.
[65 FR
70245, Nov. 21, 2000 as amended at 66 FR 35885, July 9, 2001] |