U. S. Department of Labor
November 20, 2000
Patients Rights Claims Procedure Regulation
In the years since 1977, when the Department first adopted a benefit claims
regulation under ERISA, the health care industry has seen dramatic changes.
Those changes have shifted the usual method of delivery of health care from
doctors making independent medical decisions, while indemnity insurance
companies decide later whether to pay, to integrated delivery systems under
which managed care organizations review and oversee doctors
medical decisions, often before care is provided.
The patients rights claims procedure regulation, which is now being
issued in final form, creates new important patient protections that will
ensure that group health plan participants in todays managed care
environment have access to a faster, fairer, fuller process for benefit
Faster decisions on initial claims - rather than 90 days (or more)
under current regulation, the new rule would require decisions (in most cases)
not later than:
- 72 hours for urgent care claims
- 15 days for pre-service claims
- 30 days for post-service claims
- One 15 day extension for pre- and post-service claims
Faster decisions on appeal of denied claims - rather than 60 days (or
more) under current regulation, the new rule would require decisions (in most
cases) not later than:
- 72 hours for urgent care claims
- 30 days for pre-service claims
- 60 days for post-service claims
- Claimants have more time to file appeals - 180 days, rather than current
- If treating physician determines the claim is urgent, plans
must treat as urgent.
- Plans cannot impose fees or costs as a condition to filing or appealing a
- Arbitration permitted, but only with full disclosure regarding the
process, arbitrator, relationships, right to representation, and only if
claimant agrees after completing internal appeal.
- Review must be de novo.
- Decision maker on appealed claims must be different than the person
deciding initial claim.
- Plans must consult with appropriate health care professionals in deciding
appealed claims involving medical judgment.
- Plans may not require more than two levels of review of denied claims. If
more than one level, both levels must be completed within time frame applicable
to one level.
- Special rules for the continuation or extension of approved benefits or
services to be provided over time (concurrent care decisions).
Individuals receiving approved care over a period of time must have an
opportunity for review before benefits are reduced or terminated. Also, urgent
care requests for an extension of approved benefits must be decided within 24
- Plans must have procedures and safeguards for ensuring and verifying
consistent decision making.
- Plans must notify claimant of defective filing of claim in case of
- If plans fail to make timely decisions or otherwise fail to comply with
the regulation, claimants may go to court to enforce their rights.
- Plans must provide participants a full description of the plans
- Plans must provide specific reasons for denials, including identification
of and access to any guidelines, rules, protocols relied upon in making the
- Plans must provide participants access to all documents, records and other
information relevant to the benefit determination, without regard to whether
the plan relied on the material.
- Plans must disclose the name of medical professionals consulted as part of
the claims process.
Final Rule on Summary Plan Description
- The final regulation updates and clarifies certain summary plan
description content requirements for ERISA-covered employee benefit plans.
- The SPD content regulation implements the information disclosure
recommendations of the Presidents Advisory Commission by clarifying the
information required to be disclosed to plan participants and beneficiaries, in
or as part of, the plans summary plan description, and updates the
disclosure rules applicable to both pension and welfare benefit plans. The SPD
-- Provides that health plan SPDs must describe:
- (i)any cost-sharing provisions, including premiums, deductibles, coinsurance and
copayment amounts for which the participant or beneficiary will be responsible;
- (ii) any annual or lifetime caps or other limits on benefits under the plan;
- (iii) the extent to which preventive services are covered under the plan;
- (iv)whether, and under what circumstances, existing and news drugs are covered
under the plan;
- (v) whether, and under what circumstances, coverage is provided
for medical tests, devices and procedures;
- (vi) provisions governing the use of
network providers, the composition of the provider network and whether, and
under what circumstances, coverage is provided for out-of-network services;
- (vii) any conditions or limits applicable to obtaining emergency medical care;
- (ix) any provisions requiring preauthorization or utilization review as a
condition to obtaining a benefit or service under the plan.
- Requires that the SPDs of pension and welfare
benefit plan describe, among other things, the procedures on qualified domestic
relation orders (QDROs) and qualified medical child support orders (QMCSCOs),
the plan sponsors authority to terminate the plan or eliminate benefits
under the plan, COBRA continuation rights, and updated information on coverage
by the Pension Benefit Guaranty Corporation and ERISA rights.
- Repeals the limited exemption relating to SPDs of
health plans that provide benefits through qualified health maintenance
organizations (HMOs). Thus, health plans that provide benefits through a
federally qualified HMO must comply with the improved SPD disclosure rule.
29 CFR 2560.503-1
- Adopts in final form regulations implementing amendments to ERISA made by
the Newborns' and Mothers' Health Protection Act. The final regulation requires
health plan SPDs to include information on requirements under federal or state
law applicable to the plan, and any health insurance coverage offered under the
plan, relating to hospital length of stay following newborn deliveries."
Consumer Information Card: What you should know about filing your health benefits claim