Content Requirements Applicable to Notification of Decisions On Review

Content Requirements Applicable To Notification of Decision On Review
Type of Plan Content Requirements

All ERISA Plans
1.The specific reasons for the adverse benefit determination.

2.Reference to the specific plan provisions on which the benefit determination is based,

3.Statement that the claimant may receive, upon request and free of charge, documents, records, and other information relevant to the claim.

4.Statement describing any voluntary appeals procedures, and a statement of the claimant’s right to bring an action in court under ERISA Section 502(a).

Group Health Plans and Plans Providing Disability Benefits
1.State any internal rule, guideline, protocol, or other similar criterion that was relied on (or, alternatively, a statement that such information will be provided on request).

2.If the determination is based on medical necessity, experimental treatment, or a similar exclusion or limit, additional explanation is required (or a statement that such additional explanation will be provided on request).

3.The following statement: “You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency.”