Health Claim Denial Transparency Act
Sponsored By: Representative McBath, Lucy [D-GA-6]
Introduced
Summary
Transparent reporting of health claim denials would require group health plans to add standardized counts and dollar amounts for claims and denials to their ERISA annual reports. The bill would also require plans to report denial reasons and the number of claims handled by automated or AI decision tools.
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- Families and plan participants would get counts of claims submitted, approved, denied, appealed, and reversed, plus totals for amounts paid and denied, and the reasons denials occurred.
- Employers and plan administrators would have to include more detailed data in ERISA reports. Plans with fewer than 100 participants must comply, but plans may omit prescription drug, mental health and substance use, or cancer claim counts if they had 20 or fewer such claims in the plan year.
- Regulators, researchers, and consumer advocates would receive standardized fields for pre service, post service, urgent care, inpatient, and outpatient claim activity, denial bases, and AI or automated decision use.
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Bill Overview
Analyzed Economic Effects
1 provisions identified: 1 benefits, 0 costs, 0 mixed.
More claim denial transparency for workers
If enacted, the Secretary of Labor would have to issue a regulation within one year. The rule would require every employer-sponsored group health plan to put many claims and denial data fields in its annual ERISA report. Required fields would include counts of claims submitted, approved, denied, appealed, and appeals reversed; counts by pre-service, post-service, urgent, inpatient, and outpatient claims; total dollars paid and denied; claims not decided within required timeframes; reasons for denials (for example, medical necessity, lack of referral, missing prior authorization, excluded services, administrative reasons); and how many claims used artificial intelligence and whether those claims were paid or denied. Plans with fewer than 100 participants would also have to comply, and simplified ERISA reports would still need at least these fields. The rule would let a plan omit counts for prescription drugs, mental health/substance use disorder benefits, or cancer-related medical/surgical benefits if the plan received 20 or fewer unique claims of that type during the plan year.
Sponsors & CoSponsors
Sponsor
McBath, Lucy [D-GA-6]
GA • D
Cosponsors
There are no cosponsors for this bill.
Roll Call Votes
No roll call votes available for this bill.
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