Does the regulation apply to a request for prior approval of a benefit or service when such prior approval is not required under the terms of the plan?
No. If the plan does not require prior approval for the benefit or service with respect to which the approval is being requested, the request is not a claim for benefits ( 2560.503-1(e)) governed by the regulation. The regulation defines pre-service claim by reference to the plans requirements, not the claimants decision to seek the medical care, nor the doctors decision to provide care. Thus, in the absence of any plan requirement for prior approval, mere requests for advance information on the plans possible coverage of items or services or advance approval of covered items or services do not constitute pre-service claims under the regulation. See 2560.503-1(m)(2).
No. If the plan does not require prior approval for the benefit or service with respect to which the approval is being requested, the request is not a claim for benefits (§ 2560.503-1(e)) governed by the regulation. The regulation defines pre-service claim by reference to the plan s requirements, not the claimant s decision to seek the medical care, nor the doctor s decision to provide care. Thus, in the absence of any plan requirement for prior approval, mere requests for advance information on the plan s possible coverage of items or services or advance approval of covered items or services do not constitute pre-service claims under the regulation. See § 2560.503-1(m)(2).
