Federal Laws

Find out what rights you and your patients have under current federal statutes and regulations, such as the Employee Retirement Income Security Act and the Medicare Advantage program.

Federal Law

Title 26-Internal Revenue-Chapter I-Subchapter D-Part 54. Pension Excise Taxes

08/30/2023 26 CFR Sections 54.9815-2719 and 54.9815-2719T

Internal claims and appeals and external review processes; Internal claims and appeals and external review processes (temporary)

ERISA-Med. Nec. Appeals-Deadlines, ERISA-Med. Nec. Decisions-Deadlines
State Law

Utah Code-Title 31A-Chapter 22-Part 6. Accident and Health Insurance

08/25/2023 Utah Section 31A-22-650

Health care preauthorization requirements

ERISA-Med. Nec. Decisions-Deadlines, Retroactive Denial, State Medical Necessity Decisions-Deadlines
Ama Policy

Third Party Payer Quantity Limits H-185.942

08/29/2023
ERISA-Med. Nec. Appeals-Deadlines, ERISA-Med. Nec. Decisions-Deadlines, State Medical Necessity Appeals-Deadlines, State Medical Necessity Decisions-Deadlines, Step Therapy Override, U.R. Criteria
Ama Policy

Private Health Insurance Formulary Transparency H-125.979

12/30/2021
ERISA-Med. Nec. Decisions-Deadlines, Med. Adv.-Med. Nec. Decisions-Deadlines, State Medical Necessity Decisions-Deadlines
Ama Policy

Prior Authorization Requirements for Post-Operative Opioids: H-95.919

10/14/2019
ERISA-Med. Nec. Decisions-Deadlines, Med. Adv.-Med. Nec. Appeals-Deadlines, Step Therapy Override
Federal Law

Title 29. Labor-Subtitle B-Chapter XXV-Subchapter G-Part 2560-Rules And Regulations For Administration And Enforcement

08/30/2023 29 CFR 2560.503-1

Claims Procedure

ERISA-Med. Nec. Appeals-Deadlines, ERISA-Med. Nec. Decisions-Deadlines, Preemption-ERISA
Federal Law

Title 42- Chapter 6A-Requirements Relating to Health Insurance Coverage-Individual and Group Market Reforms

08/30/2023 42 USC Section 300gg-19

Appeals process

ERISA-Med. Nec. Appeals-Deadlines, ERISA-Med. Nec. Decisions-Deadlines
Federal Law

Title 45-Subtitle A-Subchapter B-Part 147. Health Insurance Reform Requirements for the Group and Individual Health Insurance Markets

08/30/2023 45 CFR 147.136

Internal claims and appeals and external review processes

ERISA-Med. Nec. Appeals-Deadlines, ERISA-Med. Nec. Decisions-Deadlines
State Law

State of Vermont-Dept. of Financial Regulation-Rule H-2009-03

08/26/2023 Vermont Reg. H-2009-03

Consumer protection and quality requirements for managed care organizations

Amendments, Anti-gag clause, Anti-retaliation, Continuity of Care Post-Contract, Credentialing-Due Process-Denial of Contract, Credentialing-Patient Demographics, Directories, ERISA-Med. Nec. Decisions-Deadlines, Liability-insurer shifting to physician, Medical Necessity-Definition, Network Adequacy, OON-Payment Issues, Prohibited financial incentives, Retroactive Denial, State Medical Necessity Appeals-Deadlines, Termination, Termination-Due Process, U.R. Criteria
State Law

Washington Admin Code-Title 284-Chapter 284-43-Subchapter D. Prior Authorization and Utilization Review

08/26/2023 Washington Section 284-43-2000

Health care services utilization review-Generally

Anti-retaliation, ERISA-Med. Nec. Decisions-Deadlines, Retroactive Denial, State Medical Necessity Decisions-Deadlines, U.R. Criteria