Updated Model Notices for Internal Claims, Appeals and External Review Now Available
The U.S. Department of Labor (DOL) has released revised model notices for initial adverse benefit determinations, appeal denials and external review decisions. The models have been revised to include taglines in applicable non-English languages to reflect the most recent Culturally and Linguistically Appropriate Services (CLAS) County Data. The revised models also have a new expiration date of Aug. 31, 2028.
Background
Federal regulations require employee benefit plans to establish and maintain reasonable procedures for filing benefit claims and appeals, making claims and appeals decisions, and notifying claimants of benefit decisions. Plans that are covered by the Employee Retirement Income Security Act (ERISA) must provide timely notice of initial benefit denials and any subsequent denials upon appeal. Non-grandfathered group health plans and issuers must also comply with external review requirements under the Affordable Care Act.
To support compliance, the DOL has long provided model notices for initial adverse benefit determinations, appeal denials and external review decisions for use by plan sponsors and issuers. In November 2023, the DOL issued FAQs announcing its intent to update the model notices to reflect 2023 CLAS County Data, applicable to plan years beginning on or after Jan. 1, 2025.
Revised Notices
The following updated model notices are now available:
- Revised Model Notice of Adverse Benefit Determination;
- Revised Model Notice of Final Internal Adverse Benefit Determination; and
- Revised Model Notice of Final External Review Decision (also available in Spanish).
These revised templates are designed to help plans and issuers meet federal notice requirements while ensuring accessibility for individuals in counties with significant non-English-speaking populations.
More Information
Additional resources and the updated model notices can be found on the DOL’s Internal Claims and Appeals and External Review webpage.
Highlights
- Model notices for initial adverse benefit determinations, appeal denials and external review decisions have long been available to plan sponsors and issuers as a resource.
- The model notices have been updated to include taglines in applicable non-English languages to reflect updated guidance pertaining to CLAS County Data.
- The revised models have a new expiration date of Aug. 31, 2028.
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