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Federal framework for employer-sponsored benefit plans. Contains the claims procedures regulation at 29 CFR 2560.503-1. Preempts conflicting state law for self-funded ERISA plans.
{
"preemption": {
"erisa_self_funded": true
},
"prompt_pay": {
"clean_claim_days": null,
"interest_rate_apr": null,
"penalty_per_day_cents": null
},
"appeal_levels": [
{
"name": "Internal Appeal (group health)",
"level": 1,
"filing_days": 180,
"decision_days_pre_service": 30,
"decision_days_post_service": 60
},
{
"name": "External Review (NAIC Uniform Model Act)",
"level": 2,
"filing_days": 120,
"decision_days": 45,
"expedited_decision_hours": 72
}
],
"network_adequacy": {
"max_miles_primary": null,
"max_miles_specialty": null,
"max_wait_days_primary": null
},
"cost_sharing_caps": {
"family_max_oop_cents": null,
"individual_max_oop_cents": null
},
"timely_filing_windows": {
"appeal_days": null,
"cob_secondary_days": null,
"initial_claim_days": null,
"corrected_claim_days": null,
"reconsideration_days": null
}
}