Short answer: The appeal goes to the plan’s named fiduciary for appeals, which may be the employer or a TPA the plan designates, and it must be someone other than the person who made the denial or that person’s subordinate. With one level of appeal, the decision is due within 72 hours for urgent care, 30 days for pre-service claims and 60 days for post-service claims.
ERISA’s claims rules require a group health plan to give claimants at least 180 days after a denial to appeal. The appeal must be decided without deference to the first decision, by an appropriate named fiduciary who is neither the person who made the denial nor that person’s subordinate. If the denial turns on medical judgment, such as medical necessity or whether a treatment is experimental, the fiduciary must consult a health care professional with appropriate training and experience.
Decision deadlines on appeal for a group health plan: urgent care, as soon as possible and no later than 72 hours; pre-service, 30 days with one appeal level (15 days for each of two levels); post-service, 60 days with one appeal level (30 days for each of two levels).
Many self-funded employers delegate appeals to the TPA in the plan document and service agreement. If the employer keeps final appeal authority, it is acting as a fiduciary and needs a documented process, and anyone who sees health information must follow the plan’s HIPAA rules.