eNewsletter: Reimbursement eNewsletter for the healthcare community

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.
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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 details.