Vol. 46, No. 3
The final regulations contain the following general requirements, which apply to all plans subject to the Employee Retirement Income Security Act (ERISA):
- A plan’s claims procedures must not hamper the initiation or processing of claims.
- A plan’s claims procedures must ensure that claim determinations are made according to plan documents and applied consistently.
- SPDs must contain a full description of the plan’s claims procedures (including managed care procedures, such as preauthorization and utilization review).
- The notice of an adverse benefit determination must include a statement of the claimant’s right to pursue a civil action under ERISA following an adverse benefit determination on appeal.
- After an adverse benefit determination, claimants must be given access to all documents, records and information relevant to their claims, free of charge upon request, regardless of whether such information was relied upon in making the adverse benefit determination.