ERISA Section 503 and regulations at 29 CFR 2560.503-1 require employee benefit plans to establish procedures for resolving benefit claims under the plan, including initial claims and appeal of denied claims. The regulation requires specific information to be disclosed at different stages of the claims process. It also requires claims denial notices to be provided within specific time frames and to include specific information.
US Code:
29 USC 1133
Name of Law: Employee Retirement Income Security Act of 1974
The increased burden is due to a correction in the estimate of the burden to include post-service approved claims in the burden estimate of the number of notices. A review of FAQs issued by the agency highlighted that approved claims still could be an adverse determination if 100 percent of the claim was not paid (even if in-line with plan requirements due to co-pays, deductibles, and other cost-sharing arrangements). The adverse determination would require notice, which often occurs in the form of an explanation of benefits (EOBs).
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
1210-0053 Claims Procedure ss20.docx
Employee Benefit Plan Claims Procedure Under ERISA