DOL/EBSA SAMPLE AUDIT DOCUMENT REQUEST LIST

Transcription

1 DOL/EBSA SAMPLE AUDIT DOCUMENT REQUEST LIST Documents required for examination. Unless otherwise specified, the time period covered by this request is from January 1, 2013, to present. The examiner will need copies of all items listed on this attachment and it should be noted that additional records might be requested following a review of these items. 1. Plan document(s), including the following: a. Signed Plan Documents, Adoption Agreements, Amendments to date; b. Summary Plan Description (SPD); c. Wrap document; d. Benefits booklets; e. Employee handbooks which discuss employee benefits; f. Evidences of coverage (EOCs) and Certificates of Coverage for each medical option; g. Enrollment package provided to participants at open enrollment and new hire, including front and back of all enrollment forms; and h. Documents describing plan coverages, rules, costs, or changes to any of the above documents, including any Notices of Material Modifications. 2. Summary of Benefits and Coverage (SBC), and Uniform Glossary. 3. All contracts with service providers, including brokers, consultants, third party administrators, record-keepers, claims processors. Contracts should include any performance agreements and fee schedules reflecting compensation. a. If self-insured/self-funded, all contracts for claims processing, administrative services, and reinsurance; and b. If fully-insured, all contracts with insurance companies for the provision of health benefits. 4. Documents describing the cost of coverage for each option (e.g., HMO, PPO) under the Plan, including premiums by type of coverage (e.g., single, family), employee vs. employer share of cost of coverage, and the cost of COBRA coverage.

2 5. Documents demonstrating the premium amounts withheld from employees' paychecks and the amounts paid by the Plan in premiums/claims for the last three months. 6. Current fidelity bond policy, including all endorsements and riders, if applicable. 7. Current fiduciary insurance policy, including all endorsements and riders, if applicable. 8. Current stop-loss policy, if applicable. 9. Signed Form 5500 Annual Report filings and any associated financial statements/schedules and accountant's opinions, if applicable for the last two years filed. 10. If the Plan is collectively bargained: a. The most recent Collective Bargaining Agreement(s); and b. Access to all plan contribution records for the past 2 years, including, remittance reports submitted by contributing employers (access to be provided on date of appointment). 11. Listing of all individuals (name, position, contact information) directly or indirectly responsible for the operation, administration, and/or oversight of the Plan. This includes trustees, administrative or oversight committee members, and accounting or human resources personnel who process plan paperwork, such as enrollment, claims, participant inquiries, and premium payments. 12. If the Plan has any assets and/or trust: a. Signed copy of the Trust Agreement and any other governing documents; and b. Documents sufficient to show the Plan's income, expenses, assets, and liabilities on a quarterly basis for the period under review. 13. Samples of all COBRA notices, including general notice, election notice, qualifying event notice, notice of unavailability of continuation coverage, and notice of early termination of coverage. 14. In accordance with the Health Insurance Portability and Accountability Act of 1996, please provide the following records: a. The Plan's rules for eligibility to enroll under the terms of the Plan (including continued eligibility); b. Written procedures providing special enrollment rights (e.g. to individuals who lose other coverage or acquire a new dependent);

3 c. If any employees reside in a state with a Children's Health Insurance Program (CHIP) offering premium assistance, provide the CHIP notice informing participants of possible eligibility for premium assistance; and d. Written claims and appeal procedures established by the Plan. 15. The Plan's rules regarding coverage of medical/surgical and mental health benefits, including information as to any aggregate lifetime dollar limits and annual dollar limits, if not included in response to Request #1 above. 16. Notice to participants regarding rights under the Newborns' and Mothers' Health Protection Act (should appear in the Plan's SPD), if not included in response to Request #1 above. 17. Rules regarding pre-authorization or pre-service review for a hospital length of stay in connection with childbirth, if not included in response to Request #1 above. 18. Written description of benefits mandated by Women's Health and Cancer Rights Act (should be provided at enrollment and annually thereafter), if not included in response to Request #1 above. 19. Documents describing any wellness programs (such as smoking cessation, weight loss, or disease management programs) offered by the Plan, including a description of any reward offered as part of the program and any alternative means of participating in such a program, if not included in response to Request #1 above. 20. If the Plan is claiming or has claimed grandfathered health plan status within the meaning of Section 1251 of the Affordable Care Act, please provide the following: a. Grandfathered health plan status disclosure statement included in plan materials provided to participants; b. Records necessary to verify, explain, or clarify grandfathered status, including plan terms in effect as of March 23, 2010, any changes to cost-sharing provisions, changes to employer or employee contributions towards the cost of coverage, changes to annual or lifetime limits, and change in health insurance issuers; and c. Any applicable testing completed by the Plan to ensure the Plan's grandfathered health plan status. 21. Regardless of whether the Plan is claiming grandfathered status, please provide the following records in accordance with section 715 of ERISA as added by the Affordable Care Act, if not already provided in response to Request #1: a. Written notice describing enrollment opportunities relating to dependent coverage of children to age 26, if the Plan provides dependent coverage;

4 b. A list of participants or beneficiaries whose coverage has been rescinded, the reason for the rescission, and a copy of the written notice of rescission that was provided 30 days in advance of any rescission of coverage; and c. Documents indicating any lifetime or annual limits imposed, if applicable. d. Documents indicating any waiting periods imposed, if applicable, before coverage is effective. 22. If the Plan is NOT claiming grandfathered health plan status under section 1251 of the Affordable Care Act, please also provide the following records: a. Notice to participants of their right to designate a participating primary care provider, pediatrician, or obstetrician/gynecologist; b. Documents describing coverage of any emergency services; c. Documents describing coverage of preventive services; d. Documents describing the Plan's Internal Claim and Appeals and External Review Processes; e. Samples of an initial adverse benefit determination (denial), notice of adverse benefit determination on internal/administrative appeal (denial upheld on appeal), and final notice of adverse benefit determination on external review decision (denial upheld on external review); and f. If applicable, any contract or agreement with any independent review organization or third party administrator providing external review. 23. For all rebates (including medical loss ratio rebates, experience-rated contract rebates, and any other rebate from an insurer) received by the Plan or plan sponsor in relation to plan coverage: a. Documents detailing the amount, receipt date, source, and handling of each rebate; b. Sample of notice to participants about rebates, if applicable; c. Documents demonstrating the allocation of rebated amounts to employer and/or employees; and d. Correspondence regarding how rebates are to be used or allocated. 24. External or internal auditor's report of plan operations, including claims audits completed by a service provider or consulting firm.

5 25. Minutes of any Plan Committee, Board of Trustees/Directors, or other entity meetings where plan health benefits were discussed. 26. All Plan materials related to the Plan's compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA), including any applicable testing completed by the Plan to ensure the Plan's mental health and substance abuse benefits are provided in accordance with MHPAEA. 27. Claims lag report (e.g. report detailing amount of time from claim filing to claim payment). 28. Listing or report identifying all claims denied, paid, or paid-in-part for the Plan over $500 for the most recent six-month period Listing or report identifying all requests for prior or pre-authorization of services denied for the Plan for the most recent six-month period. 30. Listing or report identifying all claims grievances or claims appeal(s) for the Plan for the most recent six-month period. 31. Listing or report of all denial reason codes and their related definitions as currently used in the Plan's claims adjudication process. 1 Please provide the claim number, client identification number, date of service, date of claim receipt, date of claim payment, primary diagnosis code and description, all secondary diagnoses and descriptions, procedure codes and descriptions, add-on codes and descriptions, modifier codes and descriptions, copayment amounts, coinsurance amounts, deductible amounts, service location (e.g., inpatient, outpatient), billed amount, allowed amount, paid amount, and reason for denial codes and descriptions. The Department will select a sample from this listing and make a subsequent request for more detailed information v.1