To contextualize the claims procedure for health insurance cases, you may refer to the stories of Mary and Annie. We will also watch excerpts from Sicko, Michael Moore's 2007 documentary on the U.S. healthcare industry.
Mary
Mary is a twenty-something attorney, recent DePaul Law graduate who is employed by a Big Law firm. Mary had stage three brain tumors. She had the largest of the tumors removed and is undergoing treatment to kill the remaining tumor and eradicate any residual cancer cells. You may read about her story on her blog, listed under Resources. Her first post describes better and in greater detail, her prognosis and initial treatment. Currently, Mary is undergoing experimental treatment at the Mayo Clinic in Minnesota. While Mary has not posted about any issues with her health insurance company, one may find several potential issues among the episodes recorded in her postings, among them her election to have a CAT scan (Was it pre-approved?)and her experimental cancer treatment. Please read Mary's initial blog posting and reflect on ERISA health plan claims procedures that may arise.
Annie
Annie had a menisectomy during her first semester of law school. In her case, cartilage was cut from her right knee. She had a bucket tear in the cartilage. It had torn in a flap that sometimes hung down like the handle of a bucket. The tear caused mechanical problems: Annie was sometimes unable to get up from a seated position and her leg sometimes locked when she walked. Because of the mechanical problems, the doctor felt that immediate surgery was needed to avoid permanent damage. The doctor was the number one recommended surgeon by her student health insurer, Aetna. After her surgery, Aetna refused to pay for much of the surgical costs. For example, Aetna claimed that the surgeon used non-plan-approved assistant doctors, nurses, and facilities. Annie was billed in full for all of these costs.
Annie's surgeon then announced that he did not believe in physical therapy. Aetna deferred to his medical expertise. Other plan doctors refused to overrule the surgeon. In her right leg, Annie developed a rope-like knotted illiotibial band (IT band), and cramping in the calf and quadriceps. Her surgeon still refused to prescribe physical therapy. Eventually, one of her law school's parent institution's sports doctors (a physician for the basketball and soccer teams) examined her and prescribed physical therapy. Annie's physical therapist told her that her surgeon had previously worked with him, but that the surgeon was now paid bonuses by insurance companies whenever he did not refer patients to physical therapy.
Annie spent a lot of time corresponding with Aetna by mail and telephone.
Reflect on the ERISA health plan claims procedures that apply to Annie's case.
Introduction
One of the more controversial requirements under ERISA is that every participant seeking redress for an unlawfully denied benefit under an ERISA plan must first submit to an administrative review procedure maintained by the ERISA plan. Failure of the participant to exhaust these administrative review procedures within specified timeframes may result in the participant being denied access to the courts. Moreover, if a participant submits to the plan’s administrative review procedures and loses (i.e., the claim is again denied), and files a claim in court, the court may presume the correctness of the plan administrator’s decision absent a finding that the decision was arbitrary and capricious.
The rationale for the administrative claims review requirement is that it provides for a non-adversarial method of claims administration, and reduces the number of frivolous lawsuits. Thus, in cases where the administrative review procedures are properly utilized in good faith, they serve a valuable purpose. To maintain the integrity of the administrative review requirement, the U.S. Department of Labor (“DOL”) has promulgated extensive regulations setting forth minimum standards that must be satisfied. There is also a substantial body of case law regarding the proper application of ERISA’s administrative claims review procedures.
Following is a general discussion of the ERISA administrative claims review requirement, applicable DOL regulations, and relevant case law.
The rationale for the administrative claims review requirement is that it provides for a non-adversarial method of claims administration, and reduces the number of frivolous lawsuits. Thus, in cases where the administrative review procedures are properly utilized in good faith, they serve a valuable purpose. To maintain the integrity of the administrative review requirement, the U.S. Department of Labor (“DOL”) has promulgated extensive regulations setting forth minimum standards that must be satisfied. There is also a substantial body of case law regarding the proper application of ERISA’s administrative claims review procedures.
Following is a general discussion of the ERISA administrative claims review requirement, applicable DOL regulations, and relevant case law.
ERISA Section 503
ERISA Section 503 mandates that, in accordance with DOL regulations, every plan covered by ERISA must:
1. Notify participants and beneficiaries in writing of any denial of a claim for benefits, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant; and
2. Afford participants a reasonable opportunity for a full and fair review by the appropriate named fiduciary of the decision denying the claim.
1. Notify participants and beneficiaries in writing of any denial of a claim for benefits, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant; and
2. Afford participants a reasonable opportunity for a full and fair review by the appropriate named fiduciary of the decision denying the claim.
Reasonable Claims Procedures Under DOL Regulations
DOL regulations require that every ERISA plan establish and maintain reasonable procedures governing:
1. The filing of benefit claims;
2. Notification of benefit determinations; and
3. Appeal of adverse benefit determinations.
A plan’s claims procedures must meet five requirements in order to be deemed reasonable. The procedures must:
1. Comply with regulatory requirements pertaining to:
a. The procedures appropriate for the type of benefit claim (i.e., health, disability or pension plan);
b. What constitutes a “claim for benefits” for purposes of the administrative review requirement;
c. The timing of notification of benefit determinations;
d. The manner and content of the notification of benefit determination;
e. Appeal of adverse benefit determinations;
f. The timing of notification of benefit determinations on review; and
g. The manner and content of notification of benefit determinations on review.
2. Be described in the summary plan description (SPD), which must be provided to all participants under ERISA Section 102;
3. Not unduly hamper the initiation or processing of claims;
4. Not limit a person’s ability to authorize a representative to act on his or her behalf; and
5. Contain administrative processes and safeguards designed to ensure that benefit determinations are made according to the terms of the plan and are consistently applied to similarly situated claimants.
Additional requirements apply to group health plans and plans providing disability benefits. Three such requirements apply to both group health and disability benefits. A fourth requirement applies only to group health plans.
The three additional requirements that apply to group health plans and plans providing disability benefits are:
1. No more than two administrative appeals may be required before the claimant is permitted to file a civil suit in court;
2. To the extent the plan offers voluntary levels of appeal in addition to the two maximum appeal levels, the claims procedures must provide that:
a. The plan waives any right to assert that a claimant has failed to exhaust administrative remedies because the claimant did not elect to submit a benefit dispute to any such voluntary level of appeal;
b. Any statute of limitations or other defense based on timeliness is tolled during the time any such voluntary appeal is pending;
c. The claimant may only elect the voluntary levels of appeal after the two maximum levels;
d. The plan provides the claimant, upon request, sufficient information relating to the voluntary level of appeal to enable the claimant to make an informed judgment about whether to submit a benefit dispute to the voluntary level of appeal; and
e. No fees or costs are imposed on the claimant as part of the voluntary level of appeal.
3. No mandatory arbitration is required, unless the arbitration is conducted as one of the two maximum levels of appeal.
The fourth requirement that applies only to group health plans is:
4. In the case of pre-service claims (i.e., a claim for a benefit with respect to which pre-authorization is necessary in advance of obtaining medical care), if the claimant or an authorized representative fails to follow the plan’s procedures, the claimant or representative must be notified of the failure and the proper procedures to be followed. This notification must be provided as soon as possible, but not later 5 days (24 hours in the case of an urgent care claim) following the failure.
1. The filing of benefit claims;
2. Notification of benefit determinations; and
3. Appeal of adverse benefit determinations.
A plan’s claims procedures must meet five requirements in order to be deemed reasonable. The procedures must:
1. Comply with regulatory requirements pertaining to:
a. The procedures appropriate for the type of benefit claim (i.e., health, disability or pension plan);
b. What constitutes a “claim for benefits” for purposes of the administrative review requirement;
c. The timing of notification of benefit determinations;
d. The manner and content of the notification of benefit determination;
e. Appeal of adverse benefit determinations;
f. The timing of notification of benefit determinations on review; and
g. The manner and content of notification of benefit determinations on review.
2. Be described in the summary plan description (SPD), which must be provided to all participants under ERISA Section 102;
3. Not unduly hamper the initiation or processing of claims;
4. Not limit a person’s ability to authorize a representative to act on his or her behalf; and
5. Contain administrative processes and safeguards designed to ensure that benefit determinations are made according to the terms of the plan and are consistently applied to similarly situated claimants.
Additional requirements apply to group health plans and plans providing disability benefits. Three such requirements apply to both group health and disability benefits. A fourth requirement applies only to group health plans.
The three additional requirements that apply to group health plans and plans providing disability benefits are:
1. No more than two administrative appeals may be required before the claimant is permitted to file a civil suit in court;
2. To the extent the plan offers voluntary levels of appeal in addition to the two maximum appeal levels, the claims procedures must provide that:
a. The plan waives any right to assert that a claimant has failed to exhaust administrative remedies because the claimant did not elect to submit a benefit dispute to any such voluntary level of appeal;
b. Any statute of limitations or other defense based on timeliness is tolled during the time any such voluntary appeal is pending;
c. The claimant may only elect the voluntary levels of appeal after the two maximum levels;
d. The plan provides the claimant, upon request, sufficient information relating to the voluntary level of appeal to enable the claimant to make an informed judgment about whether to submit a benefit dispute to the voluntary level of appeal; and
e. No fees or costs are imposed on the claimant as part of the voluntary level of appeal.
3. No mandatory arbitration is required, unless the arbitration is conducted as one of the two maximum levels of appeal.
The fourth requirement that applies only to group health plans is:
4. In the case of pre-service claims (i.e., a claim for a benefit with respect to which pre-authorization is necessary in advance of obtaining medical care), if the claimant or an authorized representative fails to follow the plan’s procedures, the claimant or representative must be notified of the failure and the proper procedures to be followed. This notification must be provided as soon as possible, but not later 5 days (24 hours in the case of an urgent care claim) following the failure.
Adequate Notice of Benefit Determination
ERISA Section 503, as stated above, specifically mandates that a plan administrator must provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied. The DOL regulations provide detailed guidance regarding what constitutes “adequate notice” for purposes of ERISA Section 503.
Types of claims determinations that require notice under ERISA Section 503
ERISA Section 503 does not require that a participant or beneficiary be provided notice of every determination made by the plan administrator regarding benefits. Rather ERISA Section 503 and the DOL regulations only regulate certain types of benefit determinations, as more fully discussed below.
1. Adverse Benefit Determinations
Any time there is an adverse benefit determination, a participant must be given notice of the claim denial in accordance with DOL regulations. For this purpose, the term “adverse benefit determination” means a denial, reduction or termination, or a failure to provide or make payment (in whole or in part) for, a benefit. Examples of adverse benefit determinations include:
a. Denial of a participant’s eligibility for a benefit;
b. Failure to pay any part of a claim for medical benefits as a result of the application of a plan’s utilization review procedures;
c. Failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary.
2. Benefit Determinations With Respect To Urgent Care and Pre-Service Claims
Some claims are deemed to be so sensitive that a plan administrator is required to provide notice of a benefit determination even if it is not adverse. This is true of urgent care and pre-service claims.
(a) Urgent Care Claims
A plan administrator must notify a participant of any benefit determination regarding an urgent care claim (whether adverse or not). A claim involving urgent care is any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations –
1. Could seriously jeopardize the life or health of the claimant, or the ability of the claimant to regain maximum function; or
2.In the opinion of the physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
Whether a delay in a claim determination could seriously jeopardize the life or health of the claimant, or the ability of the claimant to regain maximum function, may generally be determined by any individual acting on behalf of the plan applying the judgment of a prudent layperson with an average knowledge of health and medicine. However, if a physician with knowledge of the claimant’s medical condition determines that the claim involves urgent care, the plan administrator must treat the claim accordingly.
(b) Pre-service Claims
A plan administrator must also notify a participant of any benefit determination regarding a pre-service claim (whether adverse or not). The term “pre-service claim” means any claim for a benefit under a group health plan, with respect to which the terms of the plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.
1. Adverse Benefit Determinations
Any time there is an adverse benefit determination, a participant must be given notice of the claim denial in accordance with DOL regulations. For this purpose, the term “adverse benefit determination” means a denial, reduction or termination, or a failure to provide or make payment (in whole or in part) for, a benefit. Examples of adverse benefit determinations include:
a. Denial of a participant’s eligibility for a benefit;
b. Failure to pay any part of a claim for medical benefits as a result of the application of a plan’s utilization review procedures;
c. Failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary.
2. Benefit Determinations With Respect To Urgent Care and Pre-Service Claims
Some claims are deemed to be so sensitive that a plan administrator is required to provide notice of a benefit determination even if it is not adverse. This is true of urgent care and pre-service claims.
(a) Urgent Care Claims
A plan administrator must notify a participant of any benefit determination regarding an urgent care claim (whether adverse or not). A claim involving urgent care is any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations –
1. Could seriously jeopardize the life or health of the claimant, or the ability of the claimant to regain maximum function; or
2.In the opinion of the physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
Whether a delay in a claim determination could seriously jeopardize the life or health of the claimant, or the ability of the claimant to regain maximum function, may generally be determined by any individual acting on behalf of the plan applying the judgment of a prudent layperson with an average knowledge of health and medicine. However, if a physician with knowledge of the claimant’s medical condition determines that the claim involves urgent care, the plan administrator must treat the claim accordingly.
(b) Pre-service Claims
A plan administrator must also notify a participant of any benefit determination regarding a pre-service claim (whether adverse or not). The term “pre-service claim” means any claim for a benefit under a group health plan, with respect to which the terms of the plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.
Content of Notification of Benefit Determination
The DOL regulations specify that a notification of benefit determination governed by ERISA Section 503 must include certain content. This content must be written in a manner calculated to be understood by the claimant. Certain content requirements apply to any notification of benefit determination with respect to any ERISA plan. Other content requirements apply specifically to claims under health and disability plans. The table below summarizes the content requirements applicable to all ERISA plans, as well as those applicable to health and disability plans.
Required Content of Notice of Benefit Determination
Type of Plan Required Content
All ERISA Plans
1. Statement of specific reasons for claim denial.
2. Reference to specific plan provisions.
3. Description of any additional information necessary to complete the claim.
4. Information on how to obtain review, including a specific statement of the claimant’s right to sue following an adverse determination on review.
Group health plans and plans providing disability benefits
1. Any internal rule, guideline, protocol, or other similar criterion that the plan relied on (or alternatively, a statement that such information will be provided on request).
2. If the denial is based on medical necessity or an experimental treatment exclusion or similar exclusion or limit, additional explanation, or a statement that such an additional explanation is available on request.
3. For urgent care cases, a description of the expedited review process that applies.
Required Content of Notice of Benefit Determination
Type of Plan Required Content
All ERISA Plans
1. Statement of specific reasons for claim denial.
2. Reference to specific plan provisions.
3. Description of any additional information necessary to complete the claim.
4. Information on how to obtain review, including a specific statement of the claimant’s right to sue following an adverse determination on review.
Group health plans and plans providing disability benefits
1. Any internal rule, guideline, protocol, or other similar criterion that the plan relied on (or alternatively, a statement that such information will be provided on request).
2. If the denial is based on medical necessity or an experimental treatment exclusion or similar exclusion or limit, additional explanation, or a statement that such an additional explanation is available on request.
3. For urgent care cases, a description of the expedited review process that applies.
When Notification of Benefit Determination Must be Given
DOL regulations provide specific timeframes within which a notice of benefit determination must be provided. How soon a plan administrator must provide a participant or beneficiary with a notification of a benefit determination depends on the nature of the claim. For example, a notification of benefit determination with respect to an urgent care claim must be provided much more quickly than one relating to a non-urgent care claim.
The table below summarizes the time within which a notice of benefit determination must be provided with respect to different types of claims. Each of these mandatory timeframes will be described in greater detail below.
The table below summarizes the time within which a notice of benefit determination must be provided with respect to different types of claims. Each of these mandatory timeframes will be described in greater detail below.
Time within which benefit determination must be provided
Time Within Which Benefit Determination Must Be Provided
Type of Claim Time Limit
1. General rule = 90 days
2. Disability claim = 45 days
3. Post-service health claim = 30 days
4. Pre-service health claim = 15 days
5. Urgent care health claim = 3 days
6. Claim requesting an extension of a course of medical treatment involving urgent care =1 day
1. The General Rule
In general, if a claim is wholly or partially denied, the plan administrator must notify the claimant of the adverse benefit determination within a reasonable period of time, but not later than 90 days after receipt of the claim by the plan. If special circumstances require an extension of time for processing the claim, the plan administrator must notify the claimant of the extension before the termination of the initial 90-day period. The extension cannot be longer than 90 days from the end of the initial 90-day period (i.e., the total period of time, with extensions, cannot exceed 180 days).
2. Special Rules Applicable To Health Plans
Due to the medical exigencies that may apply in connection with a health plan, special rules apply to when a claimant must be notified regarding a benefit determination with respect to these types of claims. Obviously, there are limits as to how long a participant should be required to delay necessary medical treatment while a plan administrator decides a coverage issue. Accordingly, the DOL regulations parse the types of medical claims, and when a corresponding notification of a benefit determination must be provided, more precisely. Below is a discussion regarding the rules applicable to providing notification of a benefit determination in the case of an urgent care, concurrent care, pre-service, and post-service claim.
(a.) Urgent Care Claims
In the case of an urgent care claim (as defined above), the plan administrator must notify the claimant of the plan’s benefit determination as soon as possible, taking into account the medical exigencies, but not later than 72 hours after the receipt of the claim by the plan. If the claimant fails to provide sufficient information to determine whether benefits are covered or payable under the plan, the plan administrator must notify the claimant as soon as possible, but later than 24 hours after receipt of the claim by the plan. The claimant must then be provided a reasonable time, at least 48 hours, to provide whatever information is necessary to complete the claim. Once the claim is completed, the plan administrator must notify the claimant of the plan’s benefit determination as soon as possible, but in no event later than 48 hours after the earlier of –
1. The plan’s receipt of the necessary information; or
2. The end of the period afforded the claimant to provide the necessary information.
(b.) Concurrent Care Decisions
Where a plan administrator has approved an ongoing course of medical treatment, but the treatment plan must be modified, special benefit determination rules apply. One set of rules applies where the plan administrator wishes to curtail or terminate a course of treatment. Another set of rules applies where the participant wants to extend a course of treatment.
If a course of treatment will be reduced or terminated, this constitutes an adverse benefit determination. The participant must be notified of the adverse benefit determination sufficiently in advance of any reduction or termination of the treatment plan to allow the participant to appeal and obtain a determination on review before the benefit is reduced or terminated.
If a participant asks to extend a course of treatment beyond that previously approved by the plan, and the request involves urgent care (as defined above), the claim must be made to the plan at least 24 hours before the completion of the approved treatment plan. The plan administrator must then make a benefit determination as soon as possible, taking into account the medical exigencies. However, the plan administrator must notify the claimant of the benefit determination, whether adverse or not, within 24 hours after receipt of the claim by the plan.
(c.) Pre-Service Claims
In the case of a pre-service claim (as defined above), the plan administrator must notify the claimant of the plan’s benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances. In no event may such determination be provided later than 15 days after receipt of the claim by the plan. If necessary, this period may be extended for up to 15 days, provided the claimant is notified of the need for the extension prior to the expiration of the initial 15-day period. If the extension is necessary because the claimant failed to provide required information, the claimant must be given at least 45 days to provide the information.
(d) Post-service Claims
Any claim under a health plan that is not a pre-service claim (as defined above) is deemed to be a “post-service claim.” In the case of a post-service claim, the claimant must be notified of an adverse benefit determination within a reasonable period of time, but not later than 30 days after the plan administrator’s receipt of the claim. This period may be extended for up to 15 days, provided the claimant is given notice of the extension prior to the expiration of the initial 30-day period. If additional information is needed from the claimant to complete the claim, the claimant must be allowed at least 45 days to submit the information.
Type of Claim Time Limit
1. General rule = 90 days
2. Disability claim = 45 days
3. Post-service health claim = 30 days
4. Pre-service health claim = 15 days
5. Urgent care health claim = 3 days
6. Claim requesting an extension of a course of medical treatment involving urgent care =1 day
1. The General Rule
In general, if a claim is wholly or partially denied, the plan administrator must notify the claimant of the adverse benefit determination within a reasonable period of time, but not later than 90 days after receipt of the claim by the plan. If special circumstances require an extension of time for processing the claim, the plan administrator must notify the claimant of the extension before the termination of the initial 90-day period. The extension cannot be longer than 90 days from the end of the initial 90-day period (i.e., the total period of time, with extensions, cannot exceed 180 days).
2. Special Rules Applicable To Health Plans
Due to the medical exigencies that may apply in connection with a health plan, special rules apply to when a claimant must be notified regarding a benefit determination with respect to these types of claims. Obviously, there are limits as to how long a participant should be required to delay necessary medical treatment while a plan administrator decides a coverage issue. Accordingly, the DOL regulations parse the types of medical claims, and when a corresponding notification of a benefit determination must be provided, more precisely. Below is a discussion regarding the rules applicable to providing notification of a benefit determination in the case of an urgent care, concurrent care, pre-service, and post-service claim.
(a.) Urgent Care Claims
In the case of an urgent care claim (as defined above), the plan administrator must notify the claimant of the plan’s benefit determination as soon as possible, taking into account the medical exigencies, but not later than 72 hours after the receipt of the claim by the plan. If the claimant fails to provide sufficient information to determine whether benefits are covered or payable under the plan, the plan administrator must notify the claimant as soon as possible, but later than 24 hours after receipt of the claim by the plan. The claimant must then be provided a reasonable time, at least 48 hours, to provide whatever information is necessary to complete the claim. Once the claim is completed, the plan administrator must notify the claimant of the plan’s benefit determination as soon as possible, but in no event later than 48 hours after the earlier of –
1. The plan’s receipt of the necessary information; or
2. The end of the period afforded the claimant to provide the necessary information.
(b.) Concurrent Care Decisions
Where a plan administrator has approved an ongoing course of medical treatment, but the treatment plan must be modified, special benefit determination rules apply. One set of rules applies where the plan administrator wishes to curtail or terminate a course of treatment. Another set of rules applies where the participant wants to extend a course of treatment.
If a course of treatment will be reduced or terminated, this constitutes an adverse benefit determination. The participant must be notified of the adverse benefit determination sufficiently in advance of any reduction or termination of the treatment plan to allow the participant to appeal and obtain a determination on review before the benefit is reduced or terminated.
If a participant asks to extend a course of treatment beyond that previously approved by the plan, and the request involves urgent care (as defined above), the claim must be made to the plan at least 24 hours before the completion of the approved treatment plan. The plan administrator must then make a benefit determination as soon as possible, taking into account the medical exigencies. However, the plan administrator must notify the claimant of the benefit determination, whether adverse or not, within 24 hours after receipt of the claim by the plan.
(c.) Pre-Service Claims
In the case of a pre-service claim (as defined above), the plan administrator must notify the claimant of the plan’s benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances. In no event may such determination be provided later than 15 days after receipt of the claim by the plan. If necessary, this period may be extended for up to 15 days, provided the claimant is notified of the need for the extension prior to the expiration of the initial 15-day period. If the extension is necessary because the claimant failed to provide required information, the claimant must be given at least 45 days to provide the information.
(d) Post-service Claims
Any claim under a health plan that is not a pre-service claim (as defined above) is deemed to be a “post-service claim.” In the case of a post-service claim, the claimant must be notified of an adverse benefit determination within a reasonable period of time, but not later than 30 days after the plan administrator’s receipt of the claim. This period may be extended for up to 15 days, provided the claimant is given notice of the extension prior to the expiration of the initial 30-day period. If additional information is needed from the claimant to complete the claim, the claimant must be allowed at least 45 days to submit the information.
Special Rules Applicable to Disability Benefits
Notice of an adverse benefit determination with respect to a claim for disability benefits must be given within a reasonable period of time, but not later than 45 days after receipt of the claim. An extension of up to 30 days is permitted, but only if the claimant is notified of the need for the extension prior to the expiration of the initial 45-day period. A second 30-day extension is allowed, if the claimant is notified prior to the expiration of the first 30-day extension. If any additional information is necessary to perfect the claim, the claimant must be given at least 45 days to provide the information.
Subscribe to:
Posts (Atom)
