Unravelling Healthcare’s Legal Alphabet Soup

By Jon Sistare, Attorney at Law

One of the regular things the Federal Government does is to create shortened abbreviations and acronyms for federal departments, legislation, law, regulations, positions and many other things. When I first entered the military years ago, it took me awhile to figure out what the many acronyms meant that I had to deal with. At the time, I thought it was just my small part of the Army that dealt with these things. I didn’t realize it was the whole of the federal government that uses these crazy acronyms and abbreviations.

So, in our world of health claims and appeals, we have our share of acronyms to know. If you are a curious person, this short article might (hopefully) answer a few of your questions. Here’s a list of the abbreviations or acronyms you might see on a regular basis, and what they mean.

ERISA – Employee Retirement Income Security Act. ERISA is the federal law passed in 1974 that gave rise to the governance and oversight of all employer-sponsored benefit plans, whether it is a retirement plan, or a health benefit (welfare) plan.

DOL – United States Department of Labor. For our purposes, the DOL is the federal department that has oversight of the portions of ERISA upon which we rely to assist health plans and carriers to comply with the law or regulation. The individual states get involved sometimes as well, but it is usually a state department of insurance that has the oversight at the state level. Most states do have a department of labor, but they don’t often take an active role in claims and appeals disputes.

USC – This is an abbreviation for the United States Code. The USC is the actual federal law, or federal statute (law and statute are synonymous). It is the lengthy document that in the Congress is referred to as a bill, then becomes law when signed by the President. For our purposes, ERISA is cited in the United States Code as 29 USC 1001 – 1461 et seq. That citation is the broadest citation possible and includes the part of ERISA that pertains to our purposes from the beginning to the end of the code. A citation can be more narrowly defined taking you to the specific section, paragraph and sub-paragraph. The “29” in the citation refers to a law that concerns Labor, and is enforced by the DOL. The “et seq” is a Latin term which means as amended.

CFR – This is an abbreviation for the Code of Federal Regulations. Most federal laws also have regulations that go along with the law. A regulation is the part of the oversight of the federal department that is developed by the department itself, and not by the Congress. The regulations have the force of law and provide more specific guidance on how the law to which it relates is carried out. Our primary focus is on 29 CFR 2560.503-1. The “29” again means a labor issue, the CFR means to find it in the Code of Federal Regulations, and the 2560.503-1 is the section and subsection where you will find this referenced. This citation is for the claim and appeal handling procedures that a health plan and/or carrier are required to follow.

There are thousands more of these acronyms and abbreviations used in the federal government. These are the ones I have been asked about previously by a few staff at NuLife Med. I hope they provide some clarity to the alphabet soup you might see as you work through your own claim or appeal.