,i  #aaith ,,congress  #b;d ,session    
,h4 ,r4 #iged  ,,in ,,the ,,house ,,of  
,,representatives  ,july #af1 #bjbf,mrs4
 ,mc,bath introduced the following bill2
 which was referred to the ,committee on
 ,education and ,workforce  ,a ,,bill   
,to direct the ,secretary of ,labor to  
require group health plans include      
certain information on claim denials in 
annual reports1 and for other purposes4 
#a4 ,short title ,this ,act may be cited
 as the ,health ,claim ,denial          
,transparency ,act4  #b4 ,claim denial  
transparency regulation  7a7 ,regulation
  7#a7 ,in general ,not later than #a   
year after the date of enactment of this
 ,act and subject to paragraph 7#b71 the
 ,secretary of ,labor shall promulgate a
 regulation requiring all group health  
plans1 as part of the annual report     
required under section #ajd7;a77#a7 of  
the ,employee ,retirement ,income       
,security ,act of #aigd 7#bi ,u4,s4,c4  
#ajbd7;a77#a771 to include1 with respect
 to the plan year of the annual report1 

the following3  7,a7 ,the total number  
of claims for benefits-- 7i7 submitted  
during the plan year2  7ii7 approved    
during the plan year2  7iii7 denied     
during the plan year2  7iv7 appealed    
during the plan year2 and  7v7 of the   
claims described in clause 7iv71 the    
number of claim denials reversed in     
whole or in part during the appeals     
process4  7,b7 ,the number of           
pre-service1 post-service1 and urgent   
care claims-- 7i7 submitted during the  
plan year2  7ii7 approved during the    
plan year2  7iii7 denied during the plan
 year2 and  7iv7 appealed during the    
plan year4  7,c7 ,the number of         
in-patient and out-patient claims--  7i7
 submitted during the plan year2  7ii7  
approved during the plan year2  7iii7   
denied during the plan year2 and  7iv7  
appealed during the plan year4  7,d7    
,subject to paragraph 7#b71 the number  
of claims for prescription drugs-- 7i7  
submitted during the plan year2  7ii7   
denied during the plan year2  7iii7     

approved during the plan year2 and  7iv7
 appealed during the plan year4  7,e7   
,subject to paragraph 7#b71 the number  
of claims for mental health and         
substance use disorder benefits--  7i7  
submitted during the plan year2  7ii7   
denied during the plan year2  7iii7     
approved during the plan year2 and  7iv7
 appealed during the plan year4  7,f7   
,subject to paragraph 7#b71 the number  
of claims for medical and surgical      
benefits relating to the diagnosis or   
treatment of cancer-- 7i7 submitted     
during the plan year2  7ii7 denied      
during the plan year2  7iii7 approved   
during the plan year2 and  7iv7 appealed
 during the plan year4  7,g7 ,the total 
dollar amount of--  7i7 claims paid     
during the plan year2 and  7ii7 claims  
denied during the plan year4  7,h7 ,the 
total number of claims that were not    
adjudicated within the time frame       
required by the claims procedure process
 of the plan1 established pursuant to   
section #ejc of the ,employee           

,retirement ,income ,security ,act of   
#aigd 7#bi ,u4,s4,c4 #aacc74  7,i7 ,the 
basis for denials1 including the total  
number of claims denied due to--  7i7   
medical necessity requirements2  7ii7   
lack of referral2  7iii7 lack of prior  
authorization2  7iv7 services excluded2 
7v7 administrative reasons2 and  7vi7   
other reasons determined by the         
,secretary4  7,j7 ,the number of claims 
processed in which artificial           
intelligence or other automated         
decision-making tools are utilized1     
including the number of such claims--   
7i7 paid during the plan year2 and  7ii7
 denied during the plan year4  7#b7     
,exception for certain data from small  
plans ,the ,secretary may not require   
that the annual report include1 and a   
group health plan may not include in    
such report1 the number of claims as    
described under subparagraph 7,d71 7,e71
 or 7,f7 of paragraph 7#a7 if the plan  
has received #bj or fewer unique claims 
described under the applicable paragraph

 during the plan year4  7b7  ,amending  
regulations  ,as part of the            
promulgation described in subsection    
7a71 the ,secretary shall amend section 
#bebj4ajd-df7;b77#b7 of title #bi1 ,code
 of ,federal ,regulations1 to require a 
group health plan with fewer than #ajj  
participants to comply with the         
reporting requirements of subsection    
7a74  7c7 ,waiver of minimum            
requirements ,in the case that the      
,secretary allows a group health plan to
 file a simplified report pursuant to   
section #ajd7;a77#c7 of the ,employee   
,retirement ,income ,security ,act 7#bi 
,u4,s4,c4 #ajbd7;a77#c771 the ,secretary
 shall1 at a minimum1 require the group 
health plan to include all of the       
information in subsection 7a7 in such   
simplified report4  7d7 ,definitions ,in
 this section3  7#a7  ,denial  ,the term
 denial has the meaning given the term  
adverse benefit determination in section
 #befj4ejc-a7m77#d7 of title #bi1 ,code 
of ,federal ,regulations4  7#b7 ,group  

health plan ,the term group health plan 
has the meaning given the term in       
section #gcc7;a77#a7 of the ,employee   
,retirement ,income ,security ,act of   
#aigd 7#bi ,u4,s4,c4 #aaia;b7a77#a774   
7#c7 ,post-service claim ,the term      
post-service claim has the meaning given
 the term in section #befj4ejc-a7m7 of  
title #bi1 ,code of ,federal            
,regulations4  7#d7  ,pre-service claim 
,the term pre-service claim has the     
meaning given the term in section       
#befj4ejc-a7m7 of title #bi1 ,code of   
,federal ,regulations4  7#e7  ,urgent   
care claim  ,the term urgent care claim 
has the meaning given the term claim    
involving urgent care in section        
#befj4ejc-a7m77#a7 of title #bi1 ,code  
of ,federal ,regulations4