Health Claim Denial Transparency Act

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9754 Introduced in House (IH)]

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119th CONGRESS
  2d Session
                                H. R. 9754

To direct the Secretary of Labor to require group health plans include
 certain information on claim denials in annual reports, and for other
                               purposes.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                             July 16, 2026

 Mrs. McBath introduced the following bill; 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 reports, and for other
                               purposes.

    Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Health Claim Denial Transparency
Act''.

SEC. 2. CLAIM DENIAL TRANSPARENCY REGULATION.

    (a) Regulation.--
            (1) In general.--Not later than 1 year after the date of
        enactment of this Act and subject to paragraph (2), the
        Secretary of Labor shall promulgate a regulation requiring all
        group health plans, as part of the annual report required under
        section 104(a)(1) of the Employee Retirement Income Security
        Act of 1974 (29 U.S.C. 1024(a)(1)), to include, with respect to
        the plan year of the annual report, the following:
                    (A) The total number of claims for benefits--
                            (i) submitted during the plan year;
                            (ii) approved during the plan year;
                            (iii) denied during the plan year;
                            (iv) appealed during the plan year; and
                            (v) of the claims described in clause (iv),
                        the number of claim denials reversed in whole
                        or in part during the appeals process.
                    (B) The number of pre-service, post-service, and
                urgent care claims--
                            (i) submitted during the plan year;
                            (ii) approved during the plan year;
                            (iii) denied during the plan year; and
                            (iv) appealed during the plan year.
                    (C) The number of in-patient and out-patient
                claims--
                            (i) submitted during the plan year;
                            (ii) approved during the plan year;
                            (iii) denied during the plan year; and
                            (iv) appealed during the plan year.
                    (D) Subject to paragraph (2), the number of claims
                for prescription drugs--
                            (i) submitted during the plan year;
                            (ii) denied during the plan year;
                            (iii) approved during the plan year; and
                            (iv) appealed during the plan year.
                    (E) Subject to paragraph (2), the number of claims
                for mental health and substance use disorder benefits--
                            (i) submitted during the plan year;
                            (ii) denied during the plan year;
                            (iii) approved during the plan year; and
                            (iv) appealed during the plan year.
                    (F) Subject to paragraph (2), the number of claims
                for medical and surgical benefits relating to the
                diagnosis or treatment of cancer--
                            (i) submitted during the plan year;
                            (ii) denied during the plan year;
                            (iii) approved during the plan year; and
                            (iv) appealed during the plan year.
                    (G) The total dollar amount of--
                            (i) claims paid during the plan year; and
                            (ii) claims denied during the plan year.
                    (H) The total number of claims that were not
                adjudicated within the time frame required by the
                claims procedure process of the plan, established
                pursuant to section 503 of the Employee Retirement
                Income Security Act of 1974 (29 U.S.C. 1133).
                    (I) The basis for denials, including the total
                number of claims denied due to--
                            (i) medical necessity requirements;
                            (ii) lack of referral;
                            (iii) lack of prior authorization;
                            (iv) services excluded;
                            (v) administrative reasons; and
                            (vi) other reasons determined by the
                        Secretary.
                    (J) The number of claims processed in which
                artificial intelligence or other automated decision-
                making tools are utilized, including the number of such
                claims--
                            (i) paid during the plan year; and
                            (ii) denied during the plan year.
            (2) Exception for certain data from small plans.--The
        Secretary may not require that the annual report include, and a
        group health plan may not include in such report, the number of
        claims as described under subparagraph (D), (E), or (F) of
        paragraph (1) if the plan has received 20 or fewer unique
        claims described under the applicable paragraph during the plan
        year.
    (b) Amending Regulations.--As part of the promulgation described in
subsection (a), the Secretary shall amend section 2520.104-46(b)(2) of
title 29, Code of Federal Regulations, to require a group health plan
with fewer than 100 participants to comply with the reporting
requirements of subsection (a).
    (c) Waiver of Minimum Requirements.--In the case that the Secretary
allows a group health plan to file a simplified report pursuant to
section 104(a)(3) of the Employee Retirement Income Security Act (29
U.S.C. 1024(a)(3)), the Secretary shall, at a minimum, require the
group health plan to include all of the information in subsection (a)
in such simplified report.
    (d) Definitions.--In this section:
            (1) Denial.--The term ``denial'' has the meaning given the
        term ``adverse benefit determination'' in section 2560.503-
        1(m)(4) of title 29, Code of Federal Regulations.
            (2) Group health plan.--The term ``group health plan'' has
        the meaning given the term in section 733(a)(1) of the Employee
        Retirement Income Security Act of 1974 (29 U.S.C. 1191b(a)(1)).
            (3) Post-service claim.--The term ``post-service claim''
        has the meaning given the term in section 2560.503-1(m) of
        title 29, Code of Federal Regulations.
            (4) Pre-service claim.--The term ``pre-service claim'' has
        the meaning given the term in section 2560.503-1(m) of title
        29, Code of Federal Regulations.
            (5) Urgent care claim.--The term ``urgent care claim'' has
        the meaning given the term ``claim involving urgent care'' in
        section 2560.503-1(m)(1) of title 29, Code of Federal
        Regulations.
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