| Department of Labor claim rules
The Department of Labor (DOL) has issued regulations
establishing claims procedure requirements for employee
benefit plans covered under the Employee Retirement
Income Security Act (ERISA). Regence BCBSO will apply
these regulations to individual coverage as well as
plans covered under ERISA. The DOL regulations are
effective July 1, 2002, and fall into three categories:
- Timeframes for making claim determinations
- Information disclosure to members
- Procedural requirements for appeals of adverse benefit
determinations
These regulations cover employees of group benefit
plans and affect how we do business with our members,
therefore there is little impact to the daily business
processes between your office and Regence BCBSO. The
portion of the regulation dealing with timeframes for
claim determinations requires us to allow 45 days for
a response to a request for additional information e.g.,
accident reports, medical records. Prior to July 1,
2002 our process was to close a claim if no response
was received within 21 days. We have changed our internal
procedures to allow for the 45-day timeframe.
Exclusions: Government and church employee health
plans are not subject to DOL regulations. For consistency
in administration, Regence BCBSO will apply these
regulations to government and church groups unless the
employer specifically requests to be excluded. Medicare
plans are not subject to DOL regulations, therefore,
First Choice Sixty-Five, Preferred Choice Sixty-Five
and Medicare supplement plans are excluded from DOL
regulations.
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