ERISA claim file request letter dental

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A claimant under an ERISA group health plan - which includes employer dental benefits - may ask for reasonable access to and copies of all documents, records, and other information relevant to the claim, free of charge, under 29 CFR 2560.503-1(h)(2)(iii). Paragraph (m)(8) defines relevance in four parts: relied upon; submitted, considered, or generated in the course of the determination whether or not relied upon; demonstrating compliance with the administrative processes and safeguards required by (b)(5); and, for a group health plan, a statement of policy or guidance concerning the denied treatment for the claimant's diagnosis whether or not relied upon. Two further entitlements sit in the notice-content paragraphs rather than in (m)(8): the internal rule, guideline, protocol, or other similar criterion relied on, free of charge on request, at (g)(1)(v)(A) and (j)(5)(i), and an explanation of the scientific or clinical judgment for a medical-necessity or experimental denial at (g)(1)(v)(B) and (j)(5)(ii). A group health plan must also identify the medical or vocational experts whose advice it obtained, whether or not it relied on that advice, under (h)(3)(iv). A practice writing in the patient's name needs an authorized-representative designation, not an assignment of benefits: the DOL says an assignment is generally limited to the right to receive payment, and the regulation lets each plan set its own reasonable verification procedure. It prescribes no contents for the designation.