The Employment Retirement Income Security Act of 1974 (ERISA) is a piece of federal legislation that oversees administrators of certain private and public industry retirement, health insurance and other welfare plans. These groups must adhere to certain standards when responding to claims and inquiries about these different plans. Any administrator that fails to adhere to these protocols and deadlines may be exposed to legal liabilities.
Plan administrators are required to adhere to specific time limits when evaluating medical claims and approving or denying them. How long they're given greatly depends on the type of claim that is filed.
If you file an urgent care claim, your health plan administrator is required to get back with you "as soon as possible." The U.S. Department of Labor (DOL) is the government agency that oversees this federal law. They note that plan administrators can't take any longer than 72 hours to process an urgent care claim after receiving it.
Plan administrators are expected to respond to claimants who submit pre-service claims within a "reasonable" amount of time. The DOL generally considers a decision that is rendered within 15 days of the health care plan receiving the claim to be a timely turnaround.
The DOL requires health care plan administrators to render decisions on post-service claims within a reasonable time frame as well. They allow insurers up to 30 days to respond to such submissions.
There are certain steps that plan administrators are required to take if they're missing information that's necessary to file a claim.
Plan administrators are required to let individuals with urgent care claims know if they need additional information to process the claim within 24 hours of them having received it.
If they're having difficulty meeting the 15 or 30-day deadline to process pre- or post-service claims, then the insurer is required to send the insured a letter within that time frame explaining why. That correspondence must highlight what additional information that they need to process the claim and when they expect to make a decision.
Dealing with insurance companies isn't easy. It can often feel like they're giving you the runaround. If you've tried to communicate with them and you don't feel like you're getting anywhere, then an ERISA benefits claims attorney here in Washington, D.C., may be able to help.