Health Claim Denial Transparency Act

This legislation directs the Secretary of Labor to promulgate regulations within one year, requiring all group health plans to include specific claim denial information in their annual reports under the Employee Retirement Income Security Act of 1974 (ERISA). This initiative aims to significantly enhance transparency regarding health claim denials, providing a clearer picture of how plans process and deny claims. The bill mandates that group health plans report comprehensive data, including the total number of claims submitted, approved, denied, and appealed, along with the number of denials reversed. It requires categorization of claims by type, such as pre-service, post-service, urgent care, in-patient, and out-patient, and specific categories like prescription drugs, mental health, and cancer treatment. Plans must also disclose the total dollar amount of paid and denied claims , claims not adjudicated timely, and critically, the specific basis for denials , such as medical necessity, lack of authorization, or administrative reasons. Furthermore, the bill requires reporting on claims processed using artificial intelligence or other automated decision-making tools , detailing how many were paid versus denied. The bill includes an exception for small plans, allowing those with 20 or fewer unique claims in specific categories (like prescription drugs or mental health) to omit that particular data from their reports. Additionally, the Secretary of Labor is directed to amend existing regulations to ensure that group health plans with fewer than 100 participants also comply with these new, detailed reporting requirements. Even when simplified reports are permitted, they must still include all the comprehensive claim denial information specified by this Act.