Federal agency ยท U.S. Department of Labor, Employee Benefits Security Administration
Filing a Claim for Your Health Benefits (Department of Labor booklet)
A plain federal booklet on the claim and appeal rules for workplace health plans: the documents to check, how to file, the decision timeline, and your rights after a denial.
Know before you go
It is free and written for people in private-sector workplace plans covered by the Employee Retirement Income Security Act (ERISA). The booklet says the rules generally do not reach plans run by governments or most religious bodies, so check with your plan administrator if you are unsure. It is a guide to the rules, not a form or a letter, and it does not replace the deadlines in your own plan documents.
- Cost
- Not stated. The booklet is a free web page.
- Where
- Nationwide
- How to start
- Read the sections on your summary plan description and on filing a claim, then ask your plan administrator in writing for your plan's claims procedures if you do not have them.
- Have ready
- Your summary plan description; Your summary of benefits and coverage; Your denial notice
Where this comes from
- Provider
- U.S. Department of Labor, Employee Benefits Security Administration
- Source we read
- https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/publications/filing-a-claim-for-your-health-benefits
- Date we read it
- . This is not a fresh check.
- Date the provider printed
- Not displayed
- What we checked
- We read the provider's public page. We have not verified availability, eligibility or outcomes for any individual.
Other starting points
- Program or service
Beneficiary and Family Centered Care Quality Improvement Organizations: find yours
The Medicare contractors that handle fast appeals when hospital or other care is ending too soon, and complaints about the quality of care. Each state is assigned to one of two organizations.
From Centers for Medicare & Medicaid Services
- Program or service
California Department of Managed Health Care: Independent Medical Review
California's regulator for managed care plans reviews denials of medical services, emergency payment and experimental treatment through Independent Medical Review. One form starts either a review or a consumer complaint.
From California Department of Managed Health Care
- Program or service
Center for Medicare Advocacy self-help materials
Downloadable self-help toolkits for Medicare denials involving home health care, outpatient therapy and skilled nursing facility care, from a nonprofit law organization. The page describes materials, not a helpline.
From Center for Medicare Advocacy