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, but no longer than 15 calendar days from receipt of the request.

The time period may be extended for 15 calendar days for reasons beyond the plan's control so long as the member is notified of this extension. If the extension is needed due to lack of information, the member has a minimum of 45 calendar days to provide the information. The time period for deciding the pre-service claim is tolled, or stopped temporarily, from the time the extension notice is sent until the information is received.

If a pre-service claim is improperly filed, the plan must provide notice of this failure to the member within five calendar days.

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