In this one-hour CLE session, attendees will gain practical guidance on administering ERISA group health plan claims as payors and third-party administrators. Participants will learn the core claims procedure requirements of 29 C.F.R. § 2560.503-1 — reasonableness standards, the four claim types, and determination deadlines from 72 hours for urgent care to 90 days for general claims — along with required notice content and full and fair review rights on appeal, including the 180-day filing window and de novo review for group health plans. Attendees will also come away with a working understanding of the § 514 preemption framework and dual-compliance obligations for fully insured plans, plus current litigation trends: deemed exhaustion and the shift to de novo judicial review, mental health parity enforcement, No Surprises Act integration, and growing fiduciary breach exposure for TPAs.

Insight Industries + Practices