who are qualified and have received appropriate 
training in the conduct of such activities under 
the program. 
(B) PROHIBITION
OF
CONTINGENT
COM-
PENSATION ARRANGEMENTS.—Such a program 
shall not, with respect to utilization review ac-
tivities, permit or provide compensation or any-
thing of value to its employees, agents, or con-
tractors in a manner that encourages denials of 
claims for benefits. 
(C) PROHIBITION OF CONFLICTS.—Such a 
program shall not permit a health care profes-
sional who is providing health care services to 
an individual to perform utilization review ac-
tivities in connection with the health care serv-
ices being provided to the individual. 
(3) ACCESSIBILITY OF REVIEW.—Such a pro-
gram shall provide that appropriate personnel per-
forming utilization review activities under the pro-
gram, including the utilization review administrator, 
are reasonably accessible by toll-free telephone dur-
ing normal business hours to discuss patient care 
and allow response to telephone requests, and that 
appropriate provision is made to receive and respond 
promptly to calls received during other hours.
(4) LIMITS ON FREQUENCY.—Such a program 
shall not provide for the performance of utilization 
review activities with respect to a class of services 
furnished to an individual more frequently than is 
reasonably required to assess whether the services 
under review are medically necessary and appro-
priate. 
SEC. 102. PROCEDURES FOR INITIAL CLAIMS FOR BENE-
FITS AND PRIOR AUTHORIZATION DETER-
MINATIONS. 
(a) PROCEDURES OF INITIAL CLAIMS FOR BENE-
FITS.— 
(1) IN GENERAL.—A group health plan, and a 
health insurance issuer offering health insurance 
coverage, shall— 
(A) make a determination on an initial 
claim for benefits by a participant, beneficiary, 
or enrollee (or authorized representative) re-
garding payment or coverage for items or serv-
ices under the terms and conditions of the plan 
or coverage involved, including any cost-sharing 
amount that the participant, beneficiary, or en-
rollee is required to pay with respect to such 
claim for benefits; and
(B) notify a participant, beneficiary, or en-
rollee (or authorized representative) and the 
treating health care professional involved re-
garding a determination on an initial claim for 
benefits made under the terms and conditions 
of the plan or coverage, including any cost-shar-
ing amounts that the participant, beneficiary, 
or enrollee may be required to make with re-
spect to such claim for benefits, and of the 
right of the participant, beneficiary, or enrollee 
to an internal appeal under section 103. 
(2) ACCESS TO INFORMATION.— 
(A) TIMELY PROVISION OF NECESSARY IN-
FORMATION.—With respect to an initial claim 
for benefits, the participant, beneficiary, or en-
rollee (or authorized representative) and the 
treating health care professional (if any) shall 
provide the plan or issuer with access to infor-
mation requested by the plan or issuer that is 
necessary to make a determination relating to 
the claim. Such access shall be provided not 
later than 5 days after the date on which the 
request for information is received, or, in a case 
described in subparagraph (B) or (C) of sub-
section (b)(1), by such earlier time as may be
necessary to comply with the applicable timeline 
under such subparagraph. 
(B) LIMITED
EFFECT
OF
FAILURE
ON 
PLAN
OR
ISSUER’S
OBLIGATIONS.—Failure of 
the participant, beneficiary, or enrollee to com-
ply with the requirements of subparagraph (A) 
shall not remove the obligation of the plan or 
issuer to make a decision in accordance with 
the medical exigencies of the case and as soon 
as possible, based on the available information, 
and failure to comply with the time limit estab-
lished by this paragraph shall not remove the 
obligation of the plan or issuer to comply with 
the requirements of this section. 
(3) ORAL REQUESTS.—In the case of a claim 
for benefits involving an expedited or concurrent de-
termination, a participant, beneficiary, or enrollee 
(or authorized representative) may make an initial 
claim for benefits orally, but a group health plan, or 
health insurance issuer offering health insurance 
coverage, may require that the participant, bene-
ficiary, or enrollee (or authorized representative) 
provide written confirmation of such request in a 
timely manner on a form provided by the plan or 
issuer. In the case of such an oral request for bene-
fits, the making of the request (and the timing of 
such request) shall be treated as the making at that 
time of a claim for such benefits without regard to 
whether and when a written confirmation of such re-
quest is made. 
(b) TIMELINE FOR MAKING DETERMINATIONS.— 
(1) PRIOR AUTHORIZATION DETERMINATION.— 
(A) IN GENERAL.—A group health plan, 
and a health insurance issuer offering health in-
surance coverage, shall make a prior authoriza-
tion determination on a claim for benefits 
(whether oral or written) in accordance with the 
medical exigencies of the case and as soon as 
possible, but in no case later than 14 days from 
the date on which the plan or issuer receives in-
formation that is reasonably necessary to enable 
the plan or issuer to make a determination on 
the request for prior authorization and in no 
case later than 28 days after the date of the 
claim for benefits is received. 
(B) EXPEDITED
DETERMINATION.—Not-
withstanding subparagraph (A), a group health 
plan, and a health insurance issuer offering 
health insurance coverage, shall expedite a prior 
authorization determination on a claim for ben-
efits described in such subparagraph when a re-
quest for such an expedited determination is 
made by a participant, beneficiary, or enrollee 
(or authorized representative) at any time dur-
ing the process for making a determination and 
a health care professional certifies, with the re-
quest, that a determination under the proce-
dures described in subparagraph (A) would seri-
ously jeopardize the life or health of the partici-
pant, beneficiary, or enrollee or the ability of 
the participant, beneficiary, or enrollee to main-
tain or regain maximum function. Such deter-
mination shall be made in accordance with the 
medical exigencies of the case and as soon as 
possible, but in no case later than 72 hours 
after the time the request is received by the 
plan or issuer under this subparagraph. 
(C) ONGOING CARE.— 
(i) CONCURRENT REVIEW.— 
(I) IN
GENERAL.—Subject to 
clause (ii), in the case of a concurrent 
review of ongoing care (including hos-
pitalization), which results in a termi-
nation or reduction of such care, the 
plan or issuer must provide by tele-
phone and in printed form notice of 
the concurrent review determination 
to the individual or the individual’s 
designee and the individual’s health 
care provider in accordance with the 
medical exigencies of the case and as 
soon as possible, with sufficient time 
prior to the termination or reduction 
to allow for an appeal under section 
103(b)(3) to be completed before the 
termination or reduction takes effect. 
(II) CONTENTS
OF
NOTICE.— 
Such notice shall include, with respect 
to ongoing health care items and serv-
ices, the number of ongoing services 
approved, the new total of approved 
services, the date of onset of services, 
and the next review date, if any, as 
well as a statement of the individual’s 
rights to further appeal. 
(ii) RULE OF CONSTRUCTION.—Clause 
(i) shall not be construed as requiring 
plans or issuers to provide coverage of care 
that would exceed the coverage limitations 
for such care.
(2) 
RETROSPECTIVE
DETERMINATION.—A 
group health plan, and a health insurance issuer of-
fering health insurance coverage, shall make a retro-
spective determination on a claim for benefits in ac-
cordance with the medical exigencies of the case and 
as soon as possible, but not later than 30 days after 
the date on which the plan or issuer receives infor-
mation that is reasonably necessary to enable the 
plan or issuer to make a determination on the claim, 
or, if earlier, 60 days after the date of receipt of the 
claim for benefits. 
(c) NOTICE OF A DENIAL OF A CLAIM FOR BENE-
FITS.—Written notice of a denial made under an initial 
claim for benefits shall be issued to the participant, bene-
ficiary, or enrollee (or authorized representative) and the 
treating health care professional in accordance with the 
medical exigencies of the case and as soon as possible, but 
in no case later than 2 days after the date of the deter-
mination (or, in the case described in subparagraph (B) 
or (C) of subsection (b)(1), within the 72-hour or applica-
ble period referred to in such subparagraph). 
(d) REQUIREMENTS
OF NOTICE
OF DETERMINA-
TIONS.—The written notice of a denial of a claim for bene-
fits determination under subsection (c) shall be provided 
in printed form and written in a manner calculated to be
understood by the participant, beneficiary, or enrollee and 
shall include— 
(1) the specific reasons for the determination 
(including a summary of the clinical or scientific evi-
dence used in making the determination); 
(2) the procedures for obtaining additional in-
formation concerning the determination; and 
(3) notification of the right to appeal the deter-
mination and instructions on how to initiate an ap-
peal in accordance with section 103. 
(e) DEFINITIONS.—For purposes of this part: 
(1) AUTHORIZED REPRESENTATIVE.—The term 
‘‘authorized representative’’ means, with respect to 
an individual who is a participant, beneficiary, or en-
rollee, any health care professional or other person 
acting on behalf of the individual with the individ-
ual’s consent or without such consent if the indi-
vidual is medically unable to provide such consent. 
(2) CLAIM FOR BENEFITS.—The term ‘‘claim 
for benefits’’ means any request for coverage (in-
cluding authorization of coverage), for eligibility, or 
for payment in whole or in part, for an item or serv-
ice under a group health plan or health insurance 
coverage.
(3) DENIAL
OF
CLAIM
FOR
BENEFITS.—The 
term ‘‘denial’’ means, with respect to a claim for 
benefits, a denial (in whole or in part) of, or a fail-
ure to act on a timely basis upon, the claim for ben-
efits and includes a failure to provide benefits (in-
cluding items and services) required to be provided 
under this title. 
(4) TREATING HEALTH CARE PROFESSIONAL.— 
The term ‘‘treating health care professional’’ means, 
with respect to services to be provided to a partici-
pant, beneficiary, or enrollee, a health care profes-
sional who is primarily responsible for delivering 
those services to the participant, beneficiary, or en-
rollee. 
SEC. 103. INTERNAL APPEALS OF CLAIMS DENIALS. 
(a) RIGHT TO INTERNAL APPEAL.— 
(1) IN GENERAL.—A participant, beneficiary, or 
enrollee (or authorized representative) may appeal 
any denial of a claim for benefits under section 102 
under the procedures described in this section. 
(2) TIME FOR APPEAL.— 
(A) IN GENERAL.—A group health plan, 
and a health insurance issuer offering health in-
surance coverage, shall ensure that a partici-
pant, beneficiary, or enrollee (or authorized rep-
resentative) has a period of not less than 180 
days beginning on the date of a denial of a 
claim for benefits under section 102 in which to 
appeal such denial under this section. 
(B) DATE OF DENIAL.—For purposes of 
subparagraph (A), the date of the denial shall 
be deemed to be the date as of which the partic-
ipant, beneficiary, or enrollee knew of the denial 
of the claim for benefits. 
(3) FAILURE TO ACT.—The failure of a plan or 
issuer to issue a determination on a claim for bene-
fits under section 102 within the applicable timeline 
established for such a determination under such sec-
tion is a denial of a claim for benefits for purposes 
this subtitle as of the date of the applicable deadline. 
(4) PLAN WAIVER OF INTERNAL REVIEW.—A 
group health plan, or health insurance issuer offer-
ing health insurance coverage, may waive the inter-
nal review process under this section. In such case 
the plan or issuer shall provide notice to the partici-
pant, beneficiary, or enrollee (or authorized rep-
resentative) involved, the participant, beneficiary, or 
enrollee (or authorized representative) involved shall 
be relieved of any obligation to complete the internal 
review involved, and may, at the option of such par-
ticipant, beneficiary, enrollee, or representative pro-
ceed directly to seek further appeal through external 
review under section 104 or otherwise. 
(b) TIMELINES FOR MAKING DETERMINATIONS.— 
(1) ORAL REQUESTS.—In the case of an appeal 
of a denial of a claim for benefits under this section 
that involves an expedited or concurrent determina-
tion, a participant, beneficiary, or enrollee (or au-
thorized representative) may request such appeal 
orally. A group health plan, or health insurance 
issuer offering health insurance coverage, may re-
quire that the participant, beneficiary, or enrollee 
(or authorized representative) provide written con-
firmation of such request in a timely manner on a 
form provided by the plan or issuer. In the case of 
such an oral request for an appeal of a denial, the 
making of the request (and the timing of such re-
quest) shall be treated as the making at that time 
of a request for an appeal without regard to whether 
and when a written confirmation of such request is 
made. 
(2) ACCESS TO INFORMATION.— 
(A) TIMELY PROVISION OF NECESSARY IN-
FORMATION.—With respect to an appeal of a 
denial of a claim for benefits, the participant,
beneficiary, or enrollee (or authorized represent-
ative) and the treating health care professional 
(if any) shall provide the plan or issuer with ac-
cess to information requested by the plan or 
issuer that is necessary to make a determina-
tion relating to the appeal. Such access shall be 
provided not later than 5 days after the date on 
which the request for information is received, 
or, in a case described in subparagraph (B) or 
(C) of paragraph (3), by such earlier time as 
may be necessary to comply with the applicable 
timeline under such subparagraph. 
(B) LIMITED
EFFECT
OF
FAILURE
ON 
PLAN
OR
ISSUER’S
OBLIGATIONS.—Failure of 
the participant, beneficiary, or enrollee to com-
ply with the requirements of subparagraph (A) 
shall not remove the obligation of the plan or 
issuer to make a decision in accordance with 
the medical exigencies of the case and as soon 
as possible, based on the available information, 
and failure to comply with the time limit estab-
lished by this paragraph shall not remove the 
obligation of the plan or issuer to comply with 
the requirements of this section.
(3) 
PRIOR
AUTHORIZATION
DETERMINA-
TIONS.— 
(A) IN GENERAL.—Except as provided in 
this paragraph or paragraph (4), a group 
health plan, and a health insurance issuer offer-
ing health insurance coverage, shall make a de-
termination on an appeal of a denial of a claim 
for benefits under this subsection in accordance 
with the medical exigencies of the case and as 
soon as possible, but in no case later than 14 
days from the date on which the plan or issuer 
receives information that is reasonably nec-
essary to enable the plan or issuer to make a 
determination on the appeal and in no case 
later than 28 days after the date the request 
for the appeal is received. 
(B) EXPEDITED
DETERMINATION.—Not-
withstanding subparagraph (A), a group health 
plan, and a health insurance issuer offering 
health insurance coverage, shall expedite a prior 
authorization determination on an appeal of a 
denial of a claim for benefits described in sub-
paragraph (A), when a request for such an ex-
pedited determination is made by a participant, 
beneficiary, or enrollee (or authorized represent-
ative) at any time during the process for mak-
ing a determination and a health care profes-
sional certifies, with the request, that a deter-
mination under the procedures described in sub-
paragraph (A) would seriously jeopardize the 
life or health of the participant, beneficiary, or 
enrollee or the ability of the participant, bene-
ficiary, or enrollee to maintain or regain max-
imum function. Such determination shall be 
made in accordance with the medical exigencies 
of the case and as soon as possible, but in no 
case later than 72 hours after the time the re-
quest for such appeal is received by the plan or 
issuer under this subparagraph. 
(C) ONGOING CARE DETERMINATIONS.— 
(i) IN
GENERAL.—Subject to clause 
(ii), in the case of a concurrent review de-
termination 
described 
in 
section 
102(b)(1)(C)(i)(I), which results in a ter-
mination or reduction of such care, the 
plan or issuer must provide notice of the 
determination on the appeal under this 
section by telephone and in printed form to 
the individual or the individual’s designee 
and the individual’s health care provider in
accordance with the medical exigencies of 
the case and as soon as possible, with suf-
ficient time prior to the termination or re-
duction to allow for an external appeal 
under section 104 to be completed before 
the termination or reduction takes effect. 
(ii) RULE OF CONSTRUCTION.—Clause 
(i) shall not be construed as requiring 
plans or issuers to provide coverage of care 
that would exceed the coverage limitations 
for such care. 
(4) 
RETROSPECTIVE
DETERMINATION.—A 
group health plan, and a health insurance issuer of-
fering health insurance coverage, shall make a retro-
spective determination on an appeal of a denial of a 
claim for benefits in no case later than 30 days after 
the date on which the plan or issuer receives nec-
essary information that is reasonably necessary to 
enable the plan or issuer to make a determination on 
the appeal and in no case later than 60 days after 
the date the request for the appeal is received. 
(c) CONDUCT OF REVIEW.— 
(1) IN GENERAL.—A review of a denial of a 
claim for benefits under this section shall be con-
ducted by an individual with appropriate expertise 
who was not involved in the initial determination. 
(2) PEER REVIEW OF MEDICAL DECISIONS BY 
HEALTH CARE PROFESSIONALS.—A review of an ap-
peal of a denial of a claim for benefits that is based 
on a lack of medical necessity and appropriateness, 
or based on an experimental or investigational treat-
ment, or requires an evaluation of medical facts— 
(A) 
shall 
be 
made 
by 
a 
physician 
(allopathic or osteopathic); or 
(B) in a claim for benefits provided by a 
non-physician health professional, shall be made 
by a review panel including at least one prac-
ticing non-physician health professional of the 
same or similar specialty; 
with appropriate expertise (including, in the case of 
a child, appropriate pediatric expertise) and acting 
within the appropriate scope of practice within the 
State in which the service is provided or rendered, 
who was not involved in the initial determination. 
(d) NOTICE OF DETERMINATION.— 
(1) IN GENERAL.—Written notice of a deter-
mination made under an internal appeal of a denial 
of a claim for benefits shall be issued to the partici-
pant, beneficiary, or enrollee (or authorized rep-
resentative) and the treating health care professional 
in accordance with the medical exigencies of the case 
and as soon as possible, but in no case later than 
2 days after the date of completion of the review (or, 
in the case described in subparagraph (B) or (C) of 
subsection (b)(3), within the 72-hour or applicable 
period referred to in such subparagraph). 
(2) FINAL DETERMINATION.—The decision by a 
plan or issuer under this section shall be treated as 
the final determination of the plan or issuer on a de-
nial of a claim for benefits. The failure of a plan or 
issuer to issue a determination on an appeal of a de-
nial of a claim for benefits under this section within 
the applicable timeline established for such a deter-
mination shall be treated as a final determination on 
an appeal of a denial of a claim for benefits for pur-
poses of proceeding to external review under section 
104. 
(3) REQUIREMENTS OF NOTICE.—With respect 
to a determination made under this section, the no-
tice described in paragraph (1) shall be provided in 
printed form and written in a manner calculated to 
be understood by the participant, beneficiary, or en-
rollee and shall include—
(A) the specific reasons for the determina-
tion (including a summary of the clinical or sci-
entific evidence used in making the determina-
tion); 
(B) the procedures for obtaining additional 
information concerning the determination; and 
(C) notification of the right to an inde-
pendent external review under section 104 and 
instructions on how to initiate such a review. 
SEC. 104. INDEPENDENT EXTERNAL APPEALS PROCE-
DURES. 
(a) RIGHT TO EXTERNAL APPEAL.—A group health 
plan, and a health insurance issuer offering health insur-
ance coverage, shall provide in accordance with this sec-
tion participants, beneficiaries, and enrollees (or author-
ized representatives) with access to an independent exter-
nal review for any denial of a claim for benefits. 
(b) INITIATION OF THE INDEPENDENT EXTERNAL 
REVIEW PROCESS.— 
(1) TIME
TO
FILE.—A request for an inde-
pendent external review under this section shall be 
filed with the plan or issuer not later than 180 days 
after the date on which the participant, beneficiary, 
or enrollee receives notice of the denial under section 
103(d) or notice of waiver of internal review under
section 103(a)(4) or the date on which the plan or 
issuer has failed to make a timely decision under 
section 103(d)(2) and notifies the participant or 
beneficiary that it has failed to make a timely deci-
sion and that the beneficiary must file an appeal 
with an external review entity within 180 days if the 
participant or beneficiary desires to file such an ap-
peal. 
(2) FILING OF REQUEST.— 
(A) IN
GENERAL.—Subject to the suc-
ceeding provisions of this subsection, a group 
health plan, or health insurance issuer offering 
health insurance coverage, may— 
(i) except as provided in subparagraph 
(B)(i), require that a request for review be 
in writing; 
(ii) limit the filing of such a request 
to the participant, beneficiary, or enrollee 
involved (or an authorized representative); 
(iii) except if waived by the plan or 
issuer under section 103(a)(4), condition 
access to an independent external review 
under this section upon a final determina-
tion of a denial of a claim for benefits