H.R. 9754: Health Claim Denial Transparency Act

This bill would require the U.S. Department of Labor to issue a regulation within one year that makes group health plans report more detailed information about claim denials in their annual filings under ERISA.

What health plans would have to report

For each plan year, group health plans would have to include data showing:

• The total number of claims for benefits that were submitted, approved, denied, and appealed.
• How many denials were reversed in whole or in part during the appeals process.
• Separate counts for pre-service, post-service, and urgent care claims, including how many were submitted, approved, denied, and appealed.
• Separate counts for in-patient and out-patient claims, including how many were submitted, approved, denied, and appealed.
• Separate counts for claims involving prescription drugs, mental health and substance use disorder benefits, and cancer-related medical and surgical benefits, including how many were submitted, approved, denied, and appealed.
• The total dollar amount of claims that were paid and the total dollar amount of claims that were denied.
• The number of claims that were not decided on time under the plan’s claims procedures.
• The main reasons claims were denied, such as medical necessity, lack of referral, lack of prior authorization, services excluded, administrative reasons, and other reasons the Secretary of Labor may specify.
• The number of claims processed using artificial intelligence or other automated decision-making tools, including how many of those were paid and denied.

Which plans are covered

The bill would direct the Labor Department to update its regulations so that these reporting rules apply to group health plans with fewer than 100 participants as well. If the department allows a plan to file a simplified annual report, that simplified report would still have to include this denial information.

Limits for smaller data sets

The bill includes an exception for some categories of data: if a plan had 20 or fewer unique claims in a category for prescription drugs, mental health/substance use disorder benefits, or cancer-related benefits, the plan would not have to report the detailed numbers for that category.

Key definitions

The bill uses existing ERISA and federal regulatory definitions for terms like group health plan, denial (meaning an adverse benefit determination), pre-service claim, post-service claim, and urgent care claim.

Relevant Companies

None found