This paper outlines the current process under the Employee Retirement Income and Security Act (ERISA) by which plan participants can appeal a claim denial as well as changes to the claims procedure requirements being considered by the Department of Labor. It describes state legislative activity in this area and summarizes research describing practices currently in place among managed health care organization. The paper also describes two existing models for external review of managed care plan decisions, one used by the Medicare program and another by the state of Florida.
See also the entry for the related Forum Session.
In addition, see "Emerging Issues in the Use of Binding Arbitration to Resolve Disputes Between Individuals and Health Plans" (Background Paper, November 2000).