ISSUE 44 September 25, 2007
ERISA Appeal Protections
ERISA is the federal law which governs most group health
plans. It contains a number of protections to insure that appeals are reviewed
fairly and by qualified personnel. However, many insurance carriers do not
necessarily recognize the providers' rights to pursue an appeal which complies
to the ERISA standards of review.
Of course, provider appeals still get processed by
carriers. Managed care contracts often require carriers to review provider
appeals. Further, processing provider appeals creates the "illusion of
fairness" in which providers feel they have the same recourse as the patient in
accessing a quality review process. In reality, provider appeals frequently do
not get reviewed fairly. Some of the apparent shortcomings of provider appeal
reviews include the carrier's failure to provide complete disclosure of the
basis of the denial, such as pertinent policy or plan language, and the failure
to provide expert review of the denial.
AppealLettersOnline Featured Letters
We have several letters which cite ERISA Appeal Protections including the following:
ERISA Concurrent Review Requirements under the Topic "Medical Necessity" and Subcategory "ERISA Regulations"
ERISA Urgent Precert Request under the Topic "Medical Necessity" and Subcategory "ERISA Regulations"
ERISA Request for Expert Review under the Topic "Medical Necessity" and Subcategory "ERISA Regulations"
ERISA Timely Pay Statute under the Topic "Stalled Claim" and the Subcategory "ERISA"
ERISA Denial Disclosure under the Topic "Information Request" and the Subcategory "Policy Exclusions"
It is important to remember that these letters will be more effective if a binding Assignment of Benefits signed by the patient is
attached to the appeal. The AOB is necessary to establish the providers' right to an ERISA-compliant review of these appeals.
Sign up to access these appeal letters
ERISA Appeals Audioconference - Only 4 More Days to Register!
Using ERISA law in Appeals and Contract
Renegotiation, will be Oct 2 at 11 a.m. CST. ERISA claim processing
regulations and disclosure requirements can be utilized at several key phases
of the revenue cycle to improve success on both case management and denied
claim appeals. Further, ERISA can be helpful to the patient access and contract
management specialists. Speaker Tammy Tipton will explain how ERISA can be
utilized by patient access and case management to obtain accurate insurance
verification and claim approval. Further, ERISA protections are pertinent to
post-treatment denials and can be utilized in contract renegotiation efforts to
secure basic protections to provider contracts. We will provide 6 ERISA-specific appeal letters which focus on demanding the highest quality
medical review at the insurance carrier. Further, other tools to be provided
include utilization review tracking memos, a sample ERISA-compliant assignment
of benefits and a contract renegotiation request letter. During the
presentation, we will discuss ERISA protections which can be demanded including
complete denial disclosure, full and fair review of denied claims and expert
review of denials involving medical judgment. Finally, we will look at insurance litigation which has criticized
carrier review and extended rights to a fair review to providers. For more information or to participate in this audioconference, please call
888-399-4925 or click here for