ERISA claims procedure and appeals: what employers must have in place
Group health plans must have a claims and appeals process with set timeframes. Employees will use it when a claim is denied, so employers should know where it lives and who runs it.
Six Parts of the Appeals Process.
ERISA for Employer Health Plans
The federal law behind plan duties.
Summary Plan Description Guide
Where the claims process is described.
ERISA Compliance Checklist
A checklist of plan compliance duties.
DOL Health Plan Audit Toolkit
What a government plan audit looks for.
Fiduciary Governance Services
Who is responsible for plan decisions.
COBRA Administration
Another notice-driven plan duty.
Making sure the process exists on paper and in practice.
Employees rarely read the claims procedure until a claim is denied. When that happens, they need to know where to send an appeal, how long they have and what happens next. The procedure should be in the plan documents, summarized in the materials that describe the plan and consistent with what the carrier or administrator actually does.
A common gap is who actually handles appeals. For fully insured plans the carrier usually does, and for self-funded plans a third-party administrator often does under a written agreement. Confirm in writing who is responsible and what the timelines are, and keep a copy in your compliance file. Ask counsel to review it if your plan is self-funded.
Questions About Claims and Appeals.
Plain answers for HR, finance and deal teams.
What Is a Claims Procedure?
A written process for filing a claim, getting a decision and appealing a denial, which must follow federal timeframes.
How Fast Must a Plan Decide?
For group health plans, urgent claims within 72 hours, pre-service claims within 15 days and post-service claims within 30 days, with limited extensions.
How Long Do Employees Have to Appeal?
At least 180 days after notice of a denial for group health plans.
Where Is the Process Described?
In the summary plan description and in denial notices, so keep both accurate and current.
Can a Small Employer Use This?
Often yes, though the rules and costs differ by size. Send us your situation and we will say what applies.
Do the Rules Change Each Year?
Limits and some requirements change annually, so check current figures on our limits and compliance update pages.
Who Should We Involve?
Your counsel or tax advisor on legal points, finance on cost, and a benefits advisor on design and vendors.
Can You Review What We Have Now?
Yes. Send the plan documents and renewal and we will show where things stand and what options exist.
What Should We Send You First?
Your current plan summary, the renewal, and any policy or vendor agreements that apply.
How Do We Start?
Send your renewal and the timeline for the decision. We will review it and show your options.
Where do employees find the appeals process?
In the summary plan description and the carrier’s or administrator’s materials. Make sure HR knows where those documents are and can point employees to them.
Do we need to track appeals?
It is good practice to know how many are filed and how they are resolved, since patterns can show problems with a vendor. Ask what reports your carrier or administrator can provide.
Ready? Upload your renewal, or talk it through with someone first. No cost, no obligation.
General information about claims and appeals, not legal or tax advice. Plan-specific questions belong with your counsel and tax advisor, and we will bring them in.
The Law Behind This Topic.
The laws named on this page link to the statute or regulation they come from. This is general information, not legal advice, and rules change, so check the current text and ask your counsel.
ERISA Claims Procedure Rule (29 CFR 2560.503-1)
Sets claims and appeal procedures and timeframes for employee benefit plans, including group health plans.
Definitions Under ERISA (29 U.S.C. 1002)
Defines employee welfare benefit plans and related terms under ERISA.
Related Compliance Reading.
Compliance
The page this belongs to.
Employer Benefits Guides
The full section.
Employer Benefits Compliance Updates
Recent changes employers should track.
EBSA Disaster Relief For Group Health Plans
Which health plan deadlines move after a federal disaster notice.
Selecting And Monitoring Health Plan Service Providers
How to select, monitor and document the vendors that run your group health plan, including the ERISA section 408(b)(2) fee disclosures.
Michigan Independent Review of Health Claim Denials
How the state review process works for fully insured plans and how it differs from the federal process.
Checking Your Process? Send Us Your Plan Documents.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents, two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
An independent employee benefits consulting firm. We look at the entire benefits program — cost, plan performance, risk and administration.
Switch to CFH. Unhappy with your broker? Your employees won’t notice. You will. →