Department of Labor FAQ
- What is ERISA?
ERISA is an acronym for the Employee Retirement Income Security Act of 1974.
- What types of claims are affected by DOL regulations?
All pre-service, urgent care and post-service facility, professional, dental, vision and others are affected by the regulations.
- What are adverse benefit determinations?
An adverse benefit determination is a denial, reduction of or a failure to provide or make payment.
- In the event of an adverse determination, what type of notification is sent to the member when BCBSM or BCN is handling all levels of appeal?
If there is an adverse determination, health plans must follow these guidelines.
- If a member files an appeal of an adverse determination, what type of notification to the member is required?
On an appeal, the member must be notified of his or her right to receive all "relevant" information.
- Are there any special requirements for health plans in cases involving medical judgment?
In cases involving medical judgment, the health plan must consult with a health care professional who has appropriate training.
- What is a pre-service claim?
A pre-service claim is a claim requiring pre-approval as a condition of coverage.
- How are pre-service claims affected by DOL regulations?
Members are entitled to a notice of the initial determination (whether adverse or not) on a pre-service claim within a reasonable time period.
- What are urgent claims?
Urgent claims are claims in which the time periods for making non-urgent determination could jeopardize the member's life, health or ability to regain maximum function.
- How are urgent claims affected by DOL regulations?
Health plans must use a "prudent layperson" standard to determine whether a claim is for urgent care. However, there is an exception.
- What are post-service claims?
Post-service claims are any claims that are not pre-service.
- How are post-service claims affected by DOL regulations?
If there is a post-service claim, members are entitled to a notice of an adverse benefit determination within 30 calendar days of receipt.
- Is concurrent care affected by DOL regulations?
In the case of concurrent care, a reduction or termination of ongoing care is treated as an adverse benefit determination.
- What is an appeal?
An appeal is a member's request for a review of a pre-service, urgent care or post-service claims that was initially denied by BCBSM or BCN.
- How are appeals affected by DOL regulations?
When making an appeal, we've listed what the Department of Labor says are the members' rights under the law.
- What if there is a conflict between state law and DOL regulations?
State law (Michigan Public Act 250) also applies to insured ERISA plans unless it prevents the application of the DOL regulations.
- Can members have an authorized representative pursue their claim or appeal?
BCBSM and BCN members may have an authorized representative pursue a claim or appeal.
- What are the DOL timeframes for notifying members of determinations on appeals?
The Department of Labor's timeframes for appeal determinations vary depending on what type of claim the member has: pre-service, urgent care or post-service care claim.
- Are extensions permitted for these timeframes on appeal?
There are no extensions on appeal. If we don't have all the information within the allowed timeframe, we must make our determination based on what's been provided to us.
- What types of adjustments are considered exception payments?
Find examples of the types of situations that are considered exception payments such as non-contractual benefit payments and/or payment amounts in excess of annual/lifetime maximums.
- What types of adjustments are not considered exception payments?
Find out what types of adjustments are not considered exception payments such as incorrect processing edits, group files not updated, among others.
- What is the two-step appeals process for ERISA and non-ERISA underwritten groups?
BCBSM has adopted a two-step appeals process that includes handling both levels of appeals for members.
- How do I make an appeal as a member of an ERISA self-funded group?
Department of Labor regulations generally affect appeals for self-funded ERISA groups in the following ways.
- How do I handle an appeal as a non-ERISA self-funded group member?
ERISA does not affect the appeal rights for these groups and the Insurance Commissioner has held that self-funded groups are not eligible for PA250.
- Can you authorize exception payments for ERISA groups?
DOL regulations do not make it possible for BCBSM to authorize exception payments for ERISA groups.
- What happens if you do not comply with Department of Labor regulations?
Failure to comply with DOL regulations allows members to initiate civil actions without exhausting the appeal process.