For many plan sponsors, the area of benefit claims processing is complex and leaves many unanswered questions. In an effort to provide answers to the most frequently asked questions, the U.S. Department of Labor (DOL) has developed a series of questions and answers on its website. The following are some of the most commonly asked inquiries and a summary of the DOL’s replies.
- Does the Employee Benefits Security Administration’s regulation (2560.503-1(e)) apply to benefit claims filed by persons who are both enrollees in Medicare + Choice programs and participants in an ERISA plan?
DOL: The regulation applies only to benefits provided under an ERISA plan that are outside the scope of what is regulated by the Medicare program. When a benefit is provided under an ERISA plan pursuant to a separate group arrangement between a Medicare + Choice program, we have been advised by the U.S. Health & Human Services (HHS) that the benefit would be outside the scope of what is regulated by the Medicare program.
- Does the regulation apply to a request for a determination whether an individual is eligible for coverage under a plan?
DOL: The regulation applies to coverage determinations only if they are part of a claim for benefits. The regulation defines a claim for benefits, in part, as a request for a plan benefit or benefits made by a claimant in accordance with a plan’s reasonable procedure for filing benefit claims.
- Does the regulation apply to a request for prior approval of a benefit or service when such prior approval is not required under the terms of the plan?
DOL: No. If the plan does not require prior approval for the benefit or service with respect to which the approval is being requested, the request is not a claim for benefits (2560.503-1(e)).The regulation defines pre-service claim by reference to the plan’s requirements, not the claimant’s decision to seek the medical care, nor the doctor’s decision to provide care.
- Is a plan required to treat all questions regarding benefits as claims for benefits under the plan?
DOL: No. The regulation does not govern casual inquiries about benefits or the circumstances under which benefits might be paid under the terms of a plan. On the other hand, a group health plan that requires the submission of pre-service claims, such as requests for preauthorization, is not entirely free to ignore pre-service inquiries where there is a basis for concluding that the inquirer is attempting to file or further a claim for benefits, although not acting in compliance with the plan’s claim filing procedures.
- Do the requirements applicable to group health plans apply to dental benefits offered as a stand-alone plan or as part of a group health plan?
DOL: Yes, in both cases. The regulation defines a group health plan as an employee welfare benefit plan within the meaning of ERISA section 3(1) to the extent that such plan provides medical care within the meaning of section 733(a) of ERISA.
- Do the requirements applicable to group health plans apply to prescription drug benefit programs offered as a stand-alone plan or as part of a group health plan?
DOL: Yes, in both cases. Prescription drug benefits would, like dental benefits, constitute medical care within the meaning of Section 733(a) (2).
- What benefits are disability benefits subject to the special rules applicable under the regulation for disability claims?
DOL: A benefit is a disability benefit under the regulation subject to the special rules for disability claims, if the plan conditions its availability to the claimant under a show of disability.
- Do the time frames in these rules govern the time within which claims must be paid?
DOL: No. While the regulation establishes time frames within which claims must be decided, the regulation does not address the periods within which payments that have been granted must be actually paid or services that have been approved must be actually rendered.
You can read the DOL’s complete answers to these and other pertinent questions on the DOL website at: https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/benefit-claims-procedure-regulation
