ERISA Regulations Glossary of Terms

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Adverse Benefit Determination (§ 2560.503-1(m)(4)) 

A Plan's denial, reduction, or termination of or failure to provide or make payment (in whole or in part) for a benefit.  This includes a Plan's decision that a consumer is not eligible to participate in the Plan, or a decision that a benefit or service will not be provided because it is experimental, investigational, or not medically necessary.  These decisions require significant information to be disclosed to the member of the benefit determination (see the Overview for more information).

 

Appeal

A request to a higher authority for the review or rehearing of a claim.

 

Claim for Benefits (§ 2560.503-1(e))

Any claim made for plan benefits that follows a Health Plan's reasonable procedure for filing a claim. This includes pre-service and post-service claims.

 

Day

A calendar day, not a business day.

 

Fully Insured or Fully Funded Health Plans

Plans in which the benefits administrator bears the risk for employee insurance claims.  These Plans are regulated by state regulations, but these ERISA regulations set a floor or minimum set of requirements that these health plans must follow.

 

Group Health Plan (§ 2560.503-1(m)(6))

Employee welfare benefit plan under section 3(1) of ERISA that provides medical care within the meaning of section 733(a) of ERISA.

 

Health Care Professional (§ 2560.503-1(m)(7))

A physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.

 

Pre-Service Claim (§ 2560.503-1(m)(2))

Any claim under a group health plan where the Plan must approve the claim in advance of obtaining medical care.  If a plan does not require prior approval for the claim for which the approval is being requested, it is not a "claim for benefits" governed by this ERISA regulation.

 

Post-Service Claim (§ 2560.503-1(m)(3))

Any claim or benefit under a group health plan that is not a pre-service claim.

 

Self-Insured or Self-Funded Health Plans

Plans in which the employer, rather than the health plan benefits administrators, bears the risk for employee insurance claims.  These Plans are regulated solely by ERISA.

 

Urgent Care (§ 2560.503-1(m)(1)(i))

Any case in which following the time frames non-urgent claims could either: 1) seriously jeopardize the life or health of the consumer, or their ability to regain maximum function; OR, 2) in the opinion of a physician familiar with the consumer's condition, cause the consumer severe pain that could not be treated adequately without the care or treatment that is the subject of the claim, is an urgent care claim and should be treated as such.  The prudent lay person standard applies to these determinations.  If a treating physician determines that a claim involves urgent care, it shall be treated as an urgent care claim.