Health and Disability Benefits: Reviewing a Denied Claim
Adapted from Compliance Assistance - Group Health and Disability Plans Benefit Claims Procedure Regulation (29 CFR 2560.503-1), published by the U.S. Department of Labor; selected section: D. Benefit Appeals — § 2560.503-1(h), (i) and (j). The source text is reproduced with headings and formatting adjusted for this guide.
D. Benefit Appeals — § 2560.503-1(h), (i) and (j)
The following questions generally relate to the standards, timing, and notification requirements applicable to the review of denied group health plan claims.
Q-D1: May a plan require that requests for review of adverse benefit determinations be made in writing?
A: Yes, with one exception. The regulation provides that a plan's claims procedure must provide a claimant with a reasonable opportunity for a full and fair review of a denied claim. A claims procedure that requires requests for reviews of adverse benefit determinations to be made in writing would not be unreasonable in that regard, except with respect to claims involving urgent care. In the case of urgent care claims, the regulation requires that a plan's procedures permit requests for expedited appeals to be submitted orally or in writing by the claimant. (See § 2560.503-1(h)(2) and (3)(vi).)
Q-D2: May the direct supervisor of the person(s) who makes initial claim determinations serve as the appropriate named fiduciary for purposes of reviewing those claims on appeal?
A: Yes. The only limitation that the rule imposes on who can serve as the named fiduciary for purposes of reviewing adverse benefit determinations is that the named fiduciary cannot be either the individual who made the initial benefit determination that is the subject of the appeal or a subordinate of that individual. The rule further requires that the reviewer, whoever that individual is, may not afford deference to the initial determination. That is, the reviewer must consider the full record of the claim and make an independent decision on whether it should be granted. (See § 2560.503-1(h)(3)(ii).)
Q-D3: If a group health plan provides for two levels of review, rather than one, following an adverse benefit determination, what standards, if any, govern the second level of review?
A: Where a plan provides for two levels of review on appeal, it is the view of the Department that the second level of review is subject to the same standards that apply to the first level of review. For example, the second level reviewer may not afford deference to the decision at the first level of review, and the reviewer must not be the same person who made the first level review decision on the claim or a subordinate of that person. (See §§ 2560.503-1(c)(2) and 2560.503-1(h)(3)(ii).)
Q-D4: 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?
A: In the case of preservice claims, a maximum of 15 days is provided for a benefit determination at each level. In the case of postservice claims, a maximum of 30 days is provided for a determination at each level. (See § 2560.503-1(i)(2)(ii) and (iii).)
For example, if a claimant appeals a preservice adverse benefit determination, and the plan provides for two levels of review at the appeal level, the plan must make a determination within a reasonable period of time, taking into account the medical circumstances, but no later than 15 days after receipt of the appeal. If that claim is again denied at the first level of appeal and the claimant appeals that denial to the second level review stage, the plan must again make a determination within a reasonable period of time, taking into account the medical circumstances, but not later than 15 days after the plan's receipt of the claimant's second level appeal request.
In the case of urgent care claims, the regulation does not prescribe any specific period within which a determination must be made at each level of a two-level review process for such claims. Given the principles underlying the provisions governing preservice and postservice claims, however, it is the view of the Department that each level of review of an urgent care claim would have to be completed in sufficient time to ensure that the total period for completing the reviews would not exceed the maximum period otherwise applicable to a process with only one level of review – as soon as possible, taking into account the medical exigencies, but not longer than 72 hours. (See § 2560.503-1(i)(2)(i).)
Q-D5: If a group health plan provides for two levels of review following an adverse benefit determination, how much time must a claimant be afforded to appeal the first-level review determination to the second level review?
A: Under the regulation, claimants must be afforded at least 180 days following receipt of an adverse benefit determination to appeal that determination. In the case of a plan with a two-level review process, the 180-day rule applies to the period to be afforded claimants to appeal to the first review level. While the regulation does not specifically address the period of time to be afforded claimants to pursue the second level of review, the regulation requires that a plan's procedures must nonetheless be reasonable and, therefore, it is the view of the Department that plans must afford claimants a reasonable opportunity to pursue a full and fair review at the second review level. (See § 2560.503-1(h)(1) and (3)(i).)
Q-D6: If a group health plan provides for two levels of review following an adverse benefit determination, may the plan use nonbinding arbitration as a means for deciding the appealed claim?
A: Yes. A plan's procedures may provide for arbitration of benefit disputes at one of the two levels of appeal, provided two conditions are met. First, the arbitration must be conducted in a manner that will ensure that the timeframes and notice requirements otherwise applicable to appeals will be satisfied. Second, the arbitration must be nonbinding – that is, the arbitration may not limit the claimant's ability to challenge the benefit determination in court. (See § 2560.503-1(c)(4).) The regulation also permits a plan to offer binding arbitration to a claimant after completion of the plan's appeal process. (See Q-E1 and Q-E2.)
Q-D7: May the board of trustees or committee of a multiemployer group health plan or multiemployer disability benefit plan that generally reviews appealed benefit claims at their quarterly meetings provide for two levels of appeal consistent with the regulation?
A: Yes, under limited circumstances. In general, the regulation permits plans to maintain two levels of review for adverse benefit determinations and establishes special timing rules for making benefit decisions at each level of the review process. (See §§ 2560.503-1(c)(2), 2560.503-1(i)(2)(ii) and (iii), 2560.503-1(i)(3).) The regulation also provides special timing rules applicable to boards of trustees or committees of multiemployer group health plans and multiemployer disability benefit plans, pursuant to which such plans are excepted from the otherwise applicable timing requirements. Under these rules, such boards or committees generally are permitted to defer the decisions on adverse benefit determination appeals until the next regularly scheduled meeting of the plan's board or committee. (See §§ 2560.503-1(i) (2)(iii)(B), 2560.503-1(i)(3)(ii).) It is the view of the Department that a multiemployer group health plan or a disability benefit plan could not, in a manner consistent with the regulation, rely on both the special rules governing the maintenance of two appeal levels and the special rules for regularly scheduled boards of trustees or committee meetings. On the other hand, the Department does not believe a multiemployer plan is foreclosed by the regulation from electing to make appeal determinations in accordance with the special rules governing two levels of appeal, rather than in accordance with the "quarterly meeting" provisions of the regulation. In addition, there is nothing in the regulation that would foreclose a multiemployer plan from making benefit review determinations in accordance with the "quarterly meeting" provisions and, following such determinations, providing claimants with an opportunity to voluntarily pursue an additional (second) review of their claim. (See § 2560.503-1(c)(3).)
Q-D8: Does the regulation's requirement of consultation with appropriate health care professionals limit the discretion of a plan fiduciary reviewing an adverse benefit determination with respect to the advice the fiduciary may seek in resolving the issues raised by the review?
A: The regulation requires that, for group health and disability claims, the fiduciary deciding an appeal of an adverse benefit determination based in whole or in part on a medical judgment consult with an appropriate health care professional. This requirement of consultation is intended to ensure that the fiduciary deciding a claim involving medical issues is adequately informed as to those issues. The consultation requirement, however, is not intended to constrain the fiduciary from consulting any other experts the fiduciary considers appropriate under the circumstances. For example, in connection with the appeal of a denied disability claim, a fiduciary may consider it appropriate to consult with vocational or occupational experts.
In all cases, a fiduciary must take appropriate steps to resolve the appeal in a prudent manner, including acquiring necessary information and advice, weighing the advice and information so obtained, and making an independent decision on the appeal. The regulation's provision for consultation with a health care professional is not intended to alter the fiduciary standards that apply to claims adjudication.
Q-D9: Under what circumstances must a group health plan (or disability benefit plan) disclose the identity of experts consulted in the course of deciding a benefit claim?
A: The regulation provides that, in order to allow claimants a reasonable opportunity for a full and fair review of their claim, a plan's claims procedures must provide for the identification of medical (or vocational) experts whose advice was obtained on behalf of the plan in connection with an adverse benefit determination, without regard to whether the advice was relied upon in making the determination. Under the rules, plans are not required to automatically provide, as part of a notice of an adverse benefit determination or otherwise, the identity of experts consulted during the claim determination process. Nor are plans required to disclose the name of experts in the absence of an adverse benefit determination. On the other hand, consistent with the procedural requirements of the regulation, the plan must provide the identity of any such experts when requested by a claimant in connection with an adverse benefit determination. (See § 2560.503-1(h)(3)(iv) and (4).)
Q-D10: Upon receipt of a request from a claimant for the identity of experts consulted by the plan in connection with an adverse benefit determination, may a plan satisfy the requirements of the regulation by providing only the name of the company employing the expert or the qualifications of the expert, rather than the name of the expert?
A: No. The regulation expressly requires that plans provide for the identification of the medical or vocational expert or experts whose advice was obtained on behalf of the plan in connection with the claimant's claim. Consequently, merely providing the name of the company employing the expert or the qualifications of the expert would not, in the Department's view, satisfy this requirement of the regulation. (See § 2560.503-1(h)(3)(iv) and (4). Also see Q-D7.)
Q-D11: Does the regulation require that a group health plan provide a claimant with copies of the claimant's medical records relating to his or her benefit claim?
A: Yes. The regulation requires a plan to provide claimants, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to a claimant's claim for benefits. Under the regulation, "relevant documents" include, among other things, documents or records relied upon in making a benefit determination and documents and records submitted in the course of making the benefit determination. Inasmuch as a claimant's medical records relating to the benefit claim would be "relevant documents," access to, and copies of, the claimant's medical records would have to be provided upon the claimant's request. The Department notes, however, that if a plan has reason to believe that a claimant's medical records contain information that should be explained or disclosed by the physician (or other health professional) who developed the information, it would not be inconsistent with the regulation to refer the claimant to the physician (or other health professional) for such information prior to providing the requested documents directly to the claimant. However, if the physician to whom the claimant was referred failed to provide the requested information to the claimant in a reasonable period of time and without charge, the plan itself would be required to honor the claimant's request.
Q-D12: Does the regulation require that a plan provide claimants with access to or copies of files of other claimants?
A: No. The regulation requires that a claimant have access to, and copies of, documents, records and other information relevant to the claimant's claim. For this purpose, the regulation defines as "relevant" any document, record, or other information that: (i) was relied upon in making the benefit determination; (ii) was submitted, considered, or generated in the course of making the benefit determination, without regard to whether it was relied upon; (iii) demonstrates compliance with the plan's administrative processes and safeguards for ensuring consistent decisionmaking (see Q-B5); or (iv) constitutes a statement of policy or guidance with respect to the group health plan concerning the denied treatment option or benefit for the claimant's diagnosis, without regard to whether it was relied upon in making the benefit determination. (See §§ 2560.503-1(h)(2)(iii) and 2560.503-1(m)(8).)
While information and data from various claimants' files may have been compiled for purposes of developing a plan's criteria, standards, guidelines, or policies to be used in ensuring and demonstrating compliance with administrative processes and safeguards relating to consistent decisionmaking, or evaluating or assessing treatment options for benefit determinations, only the criteria, standards, guidelines, or policies themselves would have to be disclosed as information "relevant" to an individual claimant's claim, not the various claimants' files on which such criteria, standards, guidelines, or policies were based.
Q-D13: Must a plan include, in every notice of adverse benefit determination on review, a statement apprising claimants that – "You or your plan may have other voluntary dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office and your state insurance regulatory agency"?
A: The regulation, at § 2560.503-1(j)(5)(iii), provides for the inclusion of the statement described above in all notices of adverse benefit determination on review involving group health and disability claims. However, the Department recognizes that information on the specific voluntary appeal procedures offered by the plan will be provided, consistent with § 2560.503-1(j)(4), in the notice of adverse benefit determination, along with a statement of the claimant's right to bring a civil action under section 502(a) of ERISA. Pending further review, therefore, the Department will not seek to enforce compliance with the requirements of § 2560.503-1(j)(5)(iii).
This guide concerns U.S. workplace benefits and the federal rules described by the Department of Labor. The type of plan, its governing documents, and the facts of a claim matter. Government, church, and other excluded plans may follow different rules.
Source and scope
Compliance Assistance - Group Health and Disability Plans Benefit Claims Procedure Regulation (29 CFR 2560.503-1) — U.S. Department of Labor. Accessed October 28, 2026. This public domain federal guidance is an educational reference; use the source publication and the applicable plan or employment documents for the full context and later updates. Fynoptic is independent and is not endorsed by the Department of Labor.