General Rule, Group Health Plans, and Disability Claims

1. General Rule
In the case of a single employer plan, the plan administrator must notify the claimant of a benefit determination on review within a reasonable period of time, but not later than 60 days after receipt of the request for review. If an extension is required, the plan administrator must notify the claimant prior to the expiration of the initial 60-day period. The extension may not be longer than 60 days from the end of the initial 60-day period.

The normal rule described in the preceding paragraph is inapplicable to a multiemployer or other plan that has a committee or board of trustees designated as the appropriate named fiduciary. If the committee or board of trustees meets at least quarterly, the benefit determination must be made no later than the date of the meeting of the committee or board that immediately follows the plan’s receipt of the request for review. However, if the request for review is received within 30 days preceding the date of that meeting, the benefit determination may be made by the date of the second meeting following receipt of the request for review. This review period may be extended, but not later than the third meeting following the plan’s receipt of the request for review, provided proper notice is sent to the claimant prior to the commencement of the extension. The plan administrator must notify the claimant of the benefit determination on review no later than 5 days after the benefit determination is made.

2. Group Health Plans
As with the initial benefit determination, the timing of the notification of a benefit determination on review as regards a group health plan will depend on the nature of the claim. Different time periods apply to urgent care claims, pre-service claims, and post service claims, as described below.

(a.) Urgent Care Claims
The notification of a benefit determination on review with respect to an urgent care claim must be given as soon as possible, but no later than 72 hours after receipt of the claimant’s request for review. No extensions are generally permitted.

(b.) Pre-service Claims
In the case of a group health plan that provides for one appeal of an adverse benefit determination, the notification of the benefit determination on review with respect to a pre-service claim must be provided no later than 30 days after receipt of the request for review. If two appeals are permitted, the notification of benefit determination with respect to any one of the two appeals must be given within 15 days of receipt of the request for review.

(c.) Post-service Claims
In the case of a post-service claim, if the plan provides for a single appeal of an adverse benefit determination, the notification of the benefit determination on review must be provided no later than 60 days after the date of the plan’s receipt of the request for review. If two appeals are permitted, the notification of the benefit determination on review must be given no later than 30 days after the receipt of the request for review.

Post-service claims under a multiemployer or other plan governed by a committee or board of trustees are not subject to the rules described in the preceding paragraph. Rather, if the committee or board of trustees meets at least quarterly, the benefit determination on review must be made at the meeting that immediately follows the plan’s receipt of the request for review. However, if the request for review is filed within the 30 days preceding the date of that meeting, the benefit determination may be made at the second meeting following the plan’s receipt of the request for review. These time limits may be extended, but not beyond the third meeting following the plan’s receipt of the request for review. The claimant must be notified of the benefit determination on review no later than 5 days after the benefit determination is made.

3. Disability Claims
Notification of a benefit determination on review with respect to a disability claim must be provided within 45 days (regardless of whether the plan allows for one or two appeals). In the case of a multiemployer or other plan governed by a committee or board of trustees, however, rules similar to those described above with respect to post-service claims under a multiemployer group health plan apply.