Under what circumstances is a plan required to notify a claimant of a benefit determination that is not an adverse benefit determination, i.e., a complete grant of a claim?
In the case of urgent care claims and pre-service claims, the regulation requires that claimants be apprised of the plan s benefit determination, whether the determination is adverse or a complete grant. The rules require that this notification be furnished in accordance with the timeframes generally applicable to urgent care and pre-service claims. There is no specific notification requirement applicable to post-service claims that are fully granted. See ยง 2560.503-1(f)(2)(i) and (iii).
Related Questions
- If a group health plan provides for two levels of review following an adverse benefit determination, may the plan use non-binding arbitration as a means for deciding the appealed claim?
- Under what circumstances is a plan required to notify a claimant of a benefit determination that is not an adverse benefit determination, i.e., a complete grant of a claim?
- If a group health plan provides for two levels of review following an adverse benefit determination, within what period must a determination be made at each level?
