Minimum Standards for Claim Benefit Determination and Settlement
See bold sections below:
(1) All benefit determination time limits begin once the insurer receives a claim, without regard to whether all necessary information was filed with the original claim. If the insurer requires an extension due to the claimant’s failure to submit necessary information, the time for making a decision is tolled from the date the notice is sent to the claimant through:
(a) the date that the claimant provides the necessary information; or
(b) 48 hours after the end of the period afforded the claimant to provide the specified additional information.
(2) Urgent Care Claims:
(a) In a case of urgent care, an insurer shall notify the claimant of the insurer’s benefit decision, adverse or not, as soon as possible, taking into account the medical exigencies of the situation, but no later than 72 hours after the receipt of the claim
(b) It is the insurer’s duty to determine whether a claim is urgent based on the information provided by the claimant. If the claimant does not provide sufficient information for the plan to make a decision, the plan must notify the claimant as soon as possible, but not later than 24 hours after receipt of the claim, of the specific information that is required. The claimant shall be given reasonable time, but not less than 48 hours, to provide that information.
(ii) The insurer must notify the claimant of the insurer’s decision as soon as possible but not later than 48 hours after the earlier of the plan’s receipt of the requested information or the end of the time given to the claimant to provide the information.
(3) Concurrent Care Decision:
(a) Reduction or termination of concurrent care:
(i) Any reduction in the course of treatment is considered an adverse benefit determination.
(ii) The insurer must give the claimant notice, with sufficient time to appeal that adverse benefit determination and sufficient time to receive a decision of the appeal before any reduction or termination of care occurs.
(b) Extension of concurrent care:
(i) A claimant may request an extension of treatment beyond what has already been approved.
(ii) If the request for an extension is made at least 24 hours before the end of the approved treatment, the insurer must notify the claimant of the insurer’s decision as soon as possible but no later than 24 hours after receipt of the claim.
(iii) If the request for extension does not involve urgent care, the insurer must notify the claimant of the insurer’s benefit decision using the response times for a post-service claim.
(4) Pre-Service Benefit Determination:
(a) An insurer must notify the claimant of the insurer’s benefit decision within 15 days of receipt of the request for care.
(b) If the insurer is unable to make a decision within that time due to circumstances beyond the insurer’s control, such as late receipt of medical records, it must notify the claimant before expiration of the original 15 days that it intends to extend the time and then the insurer may take as long as 15 additional days to reach a decision.
(c) If the extension is due to failure of the claimant to submit necessary information, the extension notice of delay must give specific information about what the claimant has to provide and the claimant must be given at least 45 days to submit the requested information.
(d) once the pre-service claim determination has been made and the medical care rendered, the actual claim filed for payment will be processed according to the time requirements of a post-service claim.
(5) Post-Service Claims:
(a) An insurer must notify the claimant of the insurer’s benefit decision within 30 days of receipt of the request for claim.
(b) If the insurer is unable to make a decision within that time due to circumstances beyond the insurer’s control, such as late receipt of medical records, it must notify the claimant before expiration of the original 30 days that it intends to extend the time and then the insurer may take as long as 15 additional days to reach a decision.
(c) If the extension is due to failure of the claimant to submit necessary information, the extension notice of delay must give specific information about what the claimant has to provide and the claimant must be given at least 45 days to submit the requested information.
(6) A health benefit plan is required to provide continued coverage for an ongoing course of treatment pending the outcome of an internal appeal.
(7) Except for a grandfathered individual health benefit plan as defined in 45 CFR 147.140, an insurer offering an individual health benefit plan shall provide only one level of internal appeal before the final determination is made.