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If you participate in a health plan or a plan that
provides disability benefits, you will want to know how to
file a claim for your benefits. The steps outlined below
describe some of your plan’s obligations and briefly
explain the procedures and timelines for filing a health
or disability benefits claim.
Before you file, however, be aware of the Employee
Income Retirement Security Act of 1974 (ERISA), a law that
protects your health and disability benefits and sets
standards for those who administer your plan. Among other
things, the law and rules issued by the Department of
Labor include requirements for the processing of benefit
claims, the timeline for a decision when you file a claim,
and your rights when a claim is denied.
You should know that ERISA does not cover some employee
benefit plans (such as those sponsored by government
entities and most churches). If, however, you are one of
the millions of participants and beneficiaries who depend
on health or disability benefits from a private-sector
employment-based plan, take a few minutes and read on to
learn more.
A key document related to your plan is the summary plan
description (SPD). The SPD provides a detailed overview of
the plan – how it works, what benefits it provides, and
how to file a claim for benefits. It also describes your
rights as well as your responsibilities under ERISA and
your plan. For some single-employer collectively bargained
plans, you should also check the collective bargaining
agreement’s claim filing, grievance, and appeal
procedures as they may apply to claims for health and
disability benefits.
Before you apply for health or disability benefits,
review the SPD to make sure you meet the plan’s
requirements and understand the procedures for filing a
claim. Sometimes claims procedures are contained in a
separate booklet that is handed out with your SPD. If you
do not have a copy of your plan’s SPD or claims
procedures, make a written request for one or both to your
plan’s administrator. Your plan administrator is
required to provide you with a copy.
An important first step is to check your SPD to make
sure you meet your plan’s requirements to receive
benefits. Your plan might say, for example, that a waiting
period must pass before you can enroll and receive
benefits or that a dependent is not covered after a
certain age. Also, be aware of what your plan requires to
file a claim. The SPD or claims procedure booklet must
including information on where to file, what to file, and
whom to contact if you have questions about your plan,
such as the process for providing a required pre-approval
for health benefits. Plans cannot charge any filing fees
or costs for filing claims and appeals.
If, for any reason, that information is not in the SPD
or claims procedure booklet, write your plan
administrator, your employer’s human resource department
(or the office that normally handles claims), or your
employer to notify them that you have a claim. Keep a copy
of the letter for your records. You may also want to send
the letter by certified mail, return receipt requested, so
you will have a record that the letter was received and by
whom.
If it is not you, but an authorized representative who
is filing the claim, that person should refer to the SPD
and follow your plan’s claims procedure. Your plan may
require you to complete a form to name the representative.
If it is an emergency situation, the treating physician
can automatically become your authorized representative
without you having to complete a form
When a claim is filed, be sure to keep a copy for your
records.
All health and disability benefit claims must be
decided within a specific time limit, depending on the
type of claim filed.
Group health claims are divided into three types:
urgent care, pre-service and post-service claims, with the
type of claim determining how quickly a decision must be
made. The plan must decide what type of claim it is except
when a physician determines that the urgent care is
needed.
Urgent care claims are a special kind of pre-service
claim that requires a quicker decision because your health
would be threatened if the plan took the normal time
permitted to decide a pre-service claim. If a physician
with knowledge of your medical condition tells the plan
that a pre-service claim is urgent, the plan must treat it
as an urgent care claim.
Pre-service claims are requests for approval that the
plan requires you to obtain before you get medical care,
such as preauthorization or a decision on whether a
treatment or procedure is medically necessary.
Post-service claims are all other claims for benefits
under your group health plan, including claims after
medical services have been provided, such as requests for
reimbursement or payment of the costs of the services
provided. Most claims for group health benefits are
post-service claims.
Disability claims are requests for benefits where the
plan must make a determination of disability to decide the
claim.
As noted, ERISA sets specific periods of time for plans
to evaluate your claim and inform you of the decision. The
time limits are counted in calendar days, so weekends and
holidays are included. These limits do not govern when the
benefits must be paid or provided. If you are entitled to
benefits, check your SPD for how and when benefits are
paid. Plans are required to pay or provide benefits within
a reasonable time after a claim is approved.
Urgent care claims must be decided as soon as possible,
taking into account the medical needs of the patient, but
no later than 72 hours after the plan receives the claim.
The plan must tell you within 24 hours if more information
is needed; you will have no less than 48 hours to respond.
Then the plan must decide the claim within 48 hours after
the missing information is supplied or the time to supply
it has elapsed. The plan cannot extend the time to make
the initial decision without your consent. The plan must
give you notice that your claim has been granted or denied
before the end of the time allotted for the decision. The
plan can notify you orally of the benefit determination so
long as a written notification is furnished to you no
later than three days after the oral notification.
Pre-service claims must be decided within a reasonable
period of time appropriate to the medical circumstances,
but no later than 15 days after the plan has received the
claim. The plan may extend the time period up to an
additional 15 days if, for reasons beyond the plan’s
control, the decision cannot be made within the first 15
days. The plan administrator must notify you prior to the
expiration of the first 15-day period, explaining the
reason for the delay, requesting any additional
information, and advising you when the plan expects to
make the decision. If more information is requested, you
have at least 45 days to supply it. The plan then must
decide the claim no later than 15 days after you supply
the additional information or after the period of time
allowed to supply it ends, whichever comes first. If the
plan wants more time, the plan needs your consent. The
plan must give you written notice that your claim has been
granted or denied before the end of the time allotted for
the decision.
Post-service health claims must be decided within a
reasonable period of time, but not later than 30 days
after the plan has received the claim. If, because of
reasons beyond the plan’s control, more time is needed
to review your request, the plan may extend the time
period up to an additional 15 days. However, the plan
administrator has to let you know before the end of the
first 30-day period, explaining the reason for the delay,
requesting any additional information needed, and advising
you when a final decision is expected. If more information
is requested, you have at least 45 days to supply it. The
claim then must be decided no later than 15 days after you
supply the additional information or the period of time
given by the plan to do so ends, whichever comes first.
The plan needs your consent if it wants more time after
its first extension. The plan must give you notice that
your claim has been denied in whole or in part (paying
less than 100% of the claim) before the end of the time
allotted for the decision.
Disability claims must be decided within a reasonable
period of time, but not later than 45 days after the plan
has received the claim. If, because of reasons beyond the
plan’s control, more time is needed to review your
request, the plan can extend the timeframe up to 30 days.
The plan must tell you prior to the end of the first
45-day period that additional time is needed, explaining
why, any unresolved issues and additional information
needed, and when the plan expects to render a final
decision. If more information is requested during either
extension period, you will have at least 45 days to supply
it. The claim then must be decided no later than 30 days
after you supply the additional information or the period
of time given by the plan to do so ends, whichever comes
first. The plan administrator may extend the time period
for up to another 30 days as long as it notifies you
before the first extension expires. For any additional
extensions, the plan needs your consent. The plan must
give you notice whether your claim has been denied before
the end of the time allotted for the decision.
If your claim is denied, the plan administrator must
send you a notice, either in writing or electronically,
with a detailed explanation of why your claim was denied
and a description of the appeal process. In addition, the
plan must include the plan rules, guidelines, protocols,
or exclusions (such as medical necessity or experimental
treatment) used in the decision or provide you with
instructions on how you can request a copy from the plan.
The notice may also include a specific request for you to
provide the plan with additional information in case you
wish to appeal your denial.
Claims are denied for various reasons. Perhaps the
services you received are not covered by your plan. Or,
perhaps the plan simply needs more information about your
claim. Whatever the reason, you have at least 180 days to
file an appeal (check your SPD or claims procedure to see
if your plan provides a longer period).
Use the information in your claim denial notice in
preparing your appeal. You should also be aware that the
plan must provide claimants, on request and free of
charge, copies of documents, records, and other
information relevant to the claim for benefits. The plan
also must identify, on your request, any medical or
vocational expert whose advice was obtained by the plan.
Be sure to include in your appeal all information related
to your claim, particularly any additional information or
evidence that you want the plan to consider, and get it to
the person specified in the denial notice before the end
of the 180-day period.
On appeal, your claim must be reviewed by someone new
who looks at all of the information submitted and consults
with qualified medical professionals if a medical judgment
is involved. This reviewer cannot be a subordinate of the
person who made the initial decision and must give no
consideration to that decision.
Plans have specific periods of time within which to
review your appeal, depending on the type of claim.
Urgent care claims must be reviewed as soon as
possible, taking into account the medical needs of the
patient, but not later than 72 hours after the plan
receives your request to review a denied claim.
Pre-service claims must be reviewed within a reasonable
period of time appropriate to the medical circumstances,
but not later than 30 days after the plan receives your
request to review a denied claim.
Post-service claims must be reviewed within a
reasonable period of time, but not later than 60 days
after the plan receives your request to review a denied
claim.
If a group health plan needs more time, the plan must
get your consent. If you do not agree to more time, the
plan must complete the review within the permitted time
limit.
Disability claims must be reviewed within a reasonable
period of time, but not later than 45 days after the plan
receives your request to review a denied claim. If the
plan determines special circumstances exist and an
extension is needed, the plan may take up to an additional
45 days to decide the appeal. However, before taking the
extension, the plan must notify you in writing during the
first 45-day period explaining the special circumstances,
and the date by which the plan expects to make the
decision.
There are two exceptions to these time limits. In
general, single-employer collectively bargained plans may
use a collectively bargained grievance process for their
claims appeal procedure if it has provisions on filing,
determination, and review of benefit claims.
Multi-employer collectively bargained plans are given
special timeframes to allow them to schedule reviews on
appeal of post-service claims and disability claims for
the regular quarterly meetings of their boards of
trustees. If you are a participant in one of those plans
and you have questions about your plan’s procedures, you
can consult your plan’s SPD or contact the Department of
Labor’s Employee Benefits Security Administration (EBSA)
at the phone number below.
Plans can require you to go through two levels of
review of a denied health or disability claim to finish
the plan’s claims process. If two levels of review are
required, the maximum time for each review generally is
half of the time limit permitted for one review. For
example, in the case of a group health plan with one
appeal level, as noted above, the review of a pre-service
claim must be completed within a reasonable period of time
appropriate to the medical circumstances but no later than
30 days after the plan gets your appeal. If the plan
requires two appeals, each review must be completed within
15 days for pre-service claims. If your claim on appeal is
still denied after the first review, the plan has to allow
you a reasonable period of time (but not a full 180 days)
to file for the second review.
Once the final decision on your claim is made, the plan
must send you a written explanation of the decision. The
notice must be in plain language that can be understood by
participants in the plan. It must include all the specific
reasons for the denial of your claim on appeal, refer you
to the plan provisions on which the decision is based,
tell you if the plan has any additional voluntary levels
of appeal, explain your right to receive documents that
are relevant to your benefit claim free of charge, and
describe your rights to seek judicial review of the plan’s
decision.
If the plan’s final decision denies your claim, you
may want to seek legal advice regarding your rights to
bring an action in court to challenge the denial.
Normally, you must complete your plan’s claim process
before filing an action in court to challenge the denial
of a claim for benefits. However, if you believe your plan
failed to establish or follow a claims procedure
consistent with the Department’s rules described in this
booklet, you may want to seek legal advice regarding your
right to ask a court to review your benefit claim without
waiting for a decision from the plan. You also may want to
contact the nearest EBSA office about your rights if you
believe the plan failed to follow any of ERISA’s
requirements in handling your benefit claim.
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Check your plan’s benefits and claims procedure
before filing a claim. Read your SPD and contact your plan
administrator if you have questions.
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Once you claim is filed, the maximum allowable
waiting period for a decision varies by the type of claim,
ranging from 72 hours to 45 days. However, your plan can
extend certain time periods but must notify you before
doing so. Usually, you will receive a decision within this
timeframe.
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If your claim is denied, you must receive a written
notice, including specific information about why your
claim was denied and how to file an appeal.
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You have at least 180 days to request a full and
fair review of your denied claim. Use your plan’s
appeals procedure and be aware that you may need to gather
and submit new evidence or information to help the plan in
reviewing the claim.
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Reviewing your appeal can take between 72 hours and
60 days depending on the type of claim. The law and the
Department’s rules allow a disability plan additional
time if the plan’s administrator has notified you
beforehand of the need for an extension. For an appeal of
a health claim, the plan needs your permission for an
extension. The plan must send you a written notice,
telling you whether the appeal was granted or denied.
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If the appeal is denied, the written notice must
tell you the reason it was denied, describe any additional
appeal levels or voluntary appeal procedures offered by
the plan, and contain a statement regarding your rights to
seek judicial review of the plan’s decision.
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You may decide to seek legal advice if your claim’s
appeal is denied or if the plan failed to establish or
follow reasonable claims procedures. If you believe the
plan failed to follow ERISA’s requirements, you also may
want to contact the nearest EBSA office concerning your
rights under ERISA.
For the EBSA regional office nearest you or a copy of
any EBSA publications, call toll free: 1.866.444.EBSA (3272),
or visit EBSA’s Web site at: www.dol.gov/ebsa
This publication has been developed by the U.S. Department of Labor, Employee Benefits Security Administration. For a complete list of the agency's publications, call
our toll free number at 1.866.444.EBSA (3272). This material will be made available in alternate format upon request: Voice phone: 202.693.8664, TTY: 202.501.3911.
This booklet constitutes a small entity compliance guide for purposes of the Small Business Regulatory Enforcement Act of 1996.
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