ERISA claims procedure includes regulations governing the manner and content of notification of benefit determinations. ERISA notice requirements are often ignored by insurance companies and plan administrators. ERISA notice requirements for benefit determinations shall set forth the following:
1. The specific reason(s) for the adverse determination;
2. Reference to the specific plan provisions on which the determination is based;
3. 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;
4. 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; and
5. (for group health plans or disability plans) if an internal rule, guideline, protocol or similar criterion was relied upon in making the adverse benefit 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
6. 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.
7. (for urgent care) a description of the expedited review process applicable to such claims.
Contact a Skilled ERISA Attorney
The Martin Law Firm is a skilled and experienced health law firm located in southeastern Pennsylvania, just outside of Philadelphia. Attorney Jason Martin represents health care providers in ERISA matters, including issues concerning ERISA notice requirements. Contact the Martin Law Firm today to speak to an accomplished health care attorney about your ERISA legal matter.