Standards for Establishing and Maintaining Full and Fair Review

Standards for Establishing and Maintaining a Full and Fair Review
Type of Plan Applicable Full and Fair Review Standard

All ERISA Plans
1. Except for group health plans and plans providing for disability benefits (see below), claimants must have at least 60 days following receipt of a notification of an adverse benefit determination within which to appeal the determination.

2. The claimant must have an opportunity to submit comments, records, and other information.

3. The claimant must be given access to documents, records, and other information relevant to the claim.

4. The information submitted by the claimant must be taken into account, regardless of whether it was submitted or considered at the time of the initial benefit determination.

Group health plans and plans that provide disability benefits
1. At least 180 days must be allowed for filing an appeal.
2. Full and fair review must not accord deference to the initial determination.
3. The appropriate named fiduciary who reviews the claim must not be a party who made the initial decision, or be a subordinate of that party.
4. The review of any determination based on a medical judgment (including determinations of whether a treatment or drug is experimental, investigational, medically necessary, or appropriate) must be conducted in consultation with an independent health care professional who has appropriate experience in the field of medicine involved in the medical judgment.
5. Provision must be made for identifying any medical or vocational experts whose advice the plan obtained in making the benefit determination.