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Home - Employers/Brokers - Compliance - Labor Dept. Regulations
Department of Labor Regulations

The Department of Labor (DOL) has instituted comprehensive regulations on claims procedures. It's important for employers to understand them and how they affect claims payment and the appeals process. These regulations apply to all health plans, whether they are self-funded or fully insured. The main purposes of the DOL's regulations are to:

  • Deliver faster decisions - Rather than wait 90 days for decisions on new claims, in most cases, the DOL now requires decisions no later than:
    • 72 hours for urgent care claims
    • 15 days for pre-service claims
    • 30 days for post-service claims
    • One 15-day extension for pre- and post-service claims

    Rather than wait 60 days for decisions on appeals of denied claims, in most cases, the DOL now requires decisions no later than:
    • 72 hours for urgent care claims
    • 30 days for pre-service claims
    • 60 days for post-service claims

  • Develop fairer processes - These processes provide clear, easy to interpret standards for claimants and claim managers. Some new standards include:
    • Allowing claimants 180 days to file appeals
    • Requiring health plans to treat a claim as "urgent" whenever the treating physician makes that determination
    • Prohibiting plans from imposing fees for filing or appealing a claim
    • Requiring the appeals decision maker to be different than the person deciding the initial claim
    • Permitting arbitration only with full disclosure and only if the claimant agrees

  • Provide more disclosure - In order to deliver fair decisions, adequate information is needed. The DOL requires plans to:
    • Provide participants with a full description of the plan's claim procedures
    • Provide specific reasons for denials
    • Provide participants with access to all documents
    • Disclose the name of the medical professionals consulted as part of the claim

If you have questions about the DOL's current regulations, read the Department of Labor FAQs at http://www.dol.gov/ebsa/faqs/main.html and don't hesitate to contact EBC.
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