ERISA sets forth minimum requirements for employee benefit plan procedures. These are set forth at 29 C.F.R. 2560.503-1. 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.
The employee benefit plan must describe any procedures for obtaining prior approval as a prerequisite for obtaining a benefit, such as preauthorization procedures of utilization review procedures and the applicable time frames.
The claims procedures cannot preclude an authorized representative (i.e. the health care provider) of a claimant from acting on behalf of the claimant for pursuing a benefit claim or appeal of an adverse benefit determination.
Group Health Plans
For group health plans under ERISA, the claims procedures provide guidance for failure to follow the plan’s procedures for filing a pre-service claim, including notice of the failure and the proper procedures to be followed for filing a pre-service claim. The notification must be provided not later than five (5) days following the failure of twenty-four (24) hours for urgent care claims.
Benefit Determinations (whether adverse or not) must be made by the plan administrator as follows:
Urgent care claims: not later than seventy two (72) hours after receipt of the claim by the plan. If the information submitted by the claimant is insufficient to make a determination, then the plan shall notify the claimant of the insufficiency with twenty-four (24) hours after receipt of the claim.
Pre-service claims: the plan administrator shall notify the claimant not later than fifteen (15) days after receipt of the claim by the plan. This deadline may be extended one time for up to fifteen (15) additional days. If additional information is needed to make the determination, the claimant will have forty-five (45) days to provide the specified information.
Post-service claims (adverse benefit determinations only): the plan administrator shall notify the claimant not later than thirty (30) days after receipt of the claim by the plan. This may be extended one time up to fifteen (15) additional days. If additional information is needed to make the determination, the claimant will have forty-five (45) days to provide the specified information.