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Health Claims Procedures

February 9, 2001
Related Topics: Health and Wellness, Featured Article
   The Department of Labor (DOL) publishedfinal regulations on the standards for claims and appeals procedures for ERISAgroup health and disability plans. The final rules set shorter time frames fordecisions on initial health care claims, particularly for urgent medical care.

    The final regulations also set shortertime frames for review decisions of denied claims, give claimants more time tofile appeals, and require plans to provide more information to participants. Thestandards for claims appeals are stricter, such as allowing no more than twolevels of appeal before a claimant can file a federal lawsuit under ERISA forthe denied benefit.

   The final rules became effective onJanuary 20 and will apply to claims filed on or after January 1, 2002. Theeffective date refers to the date the regulation will have the force of law,although employers are not be required to actually comply with the requirementsuntil the later date.

   The regulations will requireemployer-sponsored health and disability plans to significantly modify theirclaims and appeals procedures under the plan. These regulations will generallynot cause most other types of ERISA plans, such as retirement plans and otherwelfare benefit plans, to substantially change their procedures.

    The regulation will require moreinformation to be provided to participants and beneficiaries, such as includinga description of all claims procedures in the plan's summary plan description.Certain elements of the new rules will create significant administrativeproblems and systems burdens for plans.

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SOURCE: Hewitt Associates LLC

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