Claim denial transparency regulation

(a)

Regulation

(1)

In general

Not later than 1 year after the date of enactment of this Act and subject to paragraph (2), the Secretary of Labor shall promulgate a regulation requiring all group health plans, as part of the annual report required under section 104(a)(1) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1024(a)(1)), to include, with respect to the plan year of the annual report, the following: (A)The total number of claims for benefits— (i)submitted during the plan year; (ii)approved during the plan year; (iii)denied during the plan year; (iv)appealed during the plan year; and (v)of the claims described in clause (iv), the number of claim denials reversed in whole or in part during the appeals process. (B)The number of pre-service, post-service, and urgent care claims— (i)submitted during the plan year; (ii)approved during the plan year; (iii)denied during the plan year; and (iv)appealed during the plan year. (C)The number of in-patient and out-patient claims— (i)submitted during the plan year; (ii)approved during the plan year; (iii)denied during the plan year; and (iv)appealed during the plan year. (D)Subject to paragraph (2), the number of claims for prescription drugs— (i)submitted during the plan year; (ii)denied during the plan year; (iii)approved during the plan year; and (iv)appealed during the plan year. (E)Subject to paragraph (2), the number of claims for mental health and substance use disorder benefits— (i)submitted during the plan year; (ii)denied during the plan year; (iii)approved during the plan year; and (iv)appealed during the plan year. (F)Subject to paragraph (2), the number of claims for medical and surgical benefits relating to the diagnosis or treatment of cancer— (i)submitted during the plan year; (ii)denied during the plan year; (iii)approved during the plan year; and (iv)appealed during the plan year. (G)The total dollar amount of— (i)claims paid during the plan year; and (ii)claims denied during the plan year. (H)The total number of claims that were not adjudicated within the time frame required by the claims procedure process of the plan, established pursuant to section 503 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1133). (I)The basis for denials, including the total number of claims denied due to— (i)medical necessity requirements; (ii)lack of referral; (iii)lack of prior authorization; (iv)services excluded; (v)administrative reasons; and (vi)other reasons determined by the Secretary. (J)The number of claims processed in which artificial intelligence or other automated decision-making tools are utilized, including the number of such claims— (i)paid during the plan year; and (ii)denied during the plan year. (2)

Exception for certain data from small plans

The Secretary may not require that the annual report include, and a group health plan may not include in such report, the number of claims as described under subparagraph (D), (E), or (F) of paragraph (1) if the plan has received 20 or fewer unique claims described under the applicable paragraph during the plan year. (b)

Amending regulations

As part of the promulgation described in subsection (a), the Secretary shall amend section 2520.104–46(b)(2) of title 29, Code of Federal Regulations, to require a group health plan with fewer than 100 participants to comply with the reporting requirements of subsection (a). (c)

Waiver of minimum requirements

In the case that the Secretary allows a group health plan to file a simplified report pursuant to section 104(a)(3) of the Employee Retirement Income Security Act (29 U.S.C. 1024(a)(3)), the Secretary shall, at a minimum, require the group health plan to include all of the information in subsection (a) in such simplified report. (d)

Definitions

In this section: (1)

Denial

The term denial has the meaning given the term adverse benefit determination in section 2560.503–1(m)(4) of title 29, Code of Federal Regulations. (2)

Group health plan

The term group health plan has the meaning given the term in section 733(a)(1) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1191b(a)(1)). (3)

Post-service claim

The term post-service claim has the meaning given the term in section 2560.503–1(m) of title 29, Code of Federal Regulations. (4)

Pre-service claim

The term pre-service claim has the meaning given the term in section 2560.503–1(m) of title 29, Code of Federal Regulations. (5)

Urgent care claim

The term urgent care claim has the meaning given the term claim involving urgent care in section 2560.503–1(m)(1) of title 29, Code of Federal Regulations.