Claims Procedure ERISA Requirements Checklist (Group Health Plans)

Summary

These checklists describe the enhanced standards for a group health plan's benefit claims procedure under the Employee Retirement Income Security Act (ERISA) and under the Patient Protection and Affordable Care Act (ACA). Those laws generally require plans to establish and maintain a process reasonably designed to ensure a full and fair review of benefit claims and claimant appeals of adverse determinations. The ERISA provisions reflect enhancements to the generally applicable ERISA rules and apply to any group health plan (as defined in 29 C.F.R. § 2560.503-1(m)(6)) covered by ERISA (see ERISA Coverage of Benefit Plans). The ACA incorporates the ERISA group health plan rules for internal claims procedures, with slight modifications, and adds an external review component. The ACA provisions apply to any non-grandfathered group health plan (see ERISA § 733 (29 U.S.C. § 1191b(a) and 29 C.F.R. § 2590.715-1251(a)). Note that state insurance laws concerning review procedures may also apply to group health plans (other than employer-provided self-funded plans subject to ERISA).