(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]
