For claims involving urgent care, the plan administrator must notify the claimant of the plan’s benefit determination as soon as possible. A plan administrator must provide the determination no later than 72 hours after receipt of the claim by the plan. An administrator may take beyond 72 hours if the claimant fails to provide sufficient information to determine whether benefits are covered or payable under the plan.
If a claimant fails to provide sufficient information, the plan administrator must notify the claimant of the specific information necessary to complete the claim as soon as possible and no later than 24 hours after receipt of the claim by the plan. The plan administrator must notify the claimant of the plan’s benefit determination no later than 48 hours after either the plan’s receipt of the specified information or the end of the period afforded to the claimant to provide the specified additional information.
Plan administrator must provide a claimant with either written or electronic notification of any adverse benefit determination. [Any electronic notification must comply with the standards imposed by 29 CFR 2520.104b-1(c)(1)(i), (iii), and (iv)]
In general, the notice must clearly outline:
In the case of an adverse benefit determination by a group health plan or a plan providing disability benefits, the notice must clearly outline whether the decision was based on specific criteria or medical necessity. If so, the plan administrator must provide an explanation of the criteria and that a copy of the specific criteria will be provided free of charge to the claimant upon request.
If a claim is denied in whole or in part, the plan administrator must notify the claimant of the plan’s adverse benefit determination within a reasonable amount of time, but no later than 90 days after the plan’s receipt of the claim. A plan administrator may extend the time, up to 90 days, for processing a claim if special circumstances require an extension of time. The plan administrator must provide notice of the extension to the claimant within the initial 90 days after the receipt of the claim and indicate the reasons for the extension.
If a group health plan has approved an ongoing course of treatment, an adverse benefit determination occurs when the plan reduces or terminates such treatment before the treatment ends. The plan administrator must notify the claimant in advance of the reduction or termination.
A claimant’s request to extend the course of treatment beyond the period of time or number of treatments and is a claim involving urgent care shall be decided as soon as possible. The plan administrator must notify the claimant of the benefit determination within 24 hours after receipt of the claim by the plan when 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.
For a disability claim, the plan administrator must notify the claimant 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. The plan administrator may extend the period of time for which to make a determination up to 30 days as long as the extension is necessary and notified the claim of the reason for extension and the date by which a decision may be expected before the end of the initial 45 days.
A plan administrator may receive a second extension as long as the extension is necessary and notifies the claimant of the reason for extension and the date by which a decision may be expected before the end of the initial 30 day extension. Notices of extension must explain the standards for 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.
For more information regarding Benefit Claims Procedure visit the following Department of Labor page.
For a post-service claim, the plan administrator must notify the claimant of the plan’s adverse benefit determination within a reasonable time, but not later than 30 days after the receipt of the claim. This period may be extended one time by the plan for up to 15 days if necessary due to matters beyond the control of the plan. If necessary, the plan administrator must notify the claimant of the reasons for the extension and a date by which the plan expects a decision prior to the expiration of the initial 30 day period.
If the extension is necessary due to the claimant’s failure to provide sufficient information, the notice of extension shall specifically describe the required information, and the claimant shall be allowed at least 45 days from receipt of the notice within which to provide the required information.
For a pre-service claim, the plan administrator must notify the claimant of the plan’s benefit determination within a reasonable period of time but not later than 15 days after receipt of the claim by the plan. If necessary, the time for notifying the claimant may be extended once for up to 15 days prior to the end of the initial 15 day period as long as the plan administrator notifies the claimant of reasons for the delay and the date by which a decision can be expected.
If the extension is due to the claimant’s failure to provide sufficient information, 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 specific information necessary.
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