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ERISA 1-2-3
© 2004 Jin Zhou, ERISAclaim.com
In order to make ERISA
understandable, as easy as 1-2-3, for dummies and no-brainers, we
present the official guide from DOL, Department Of Labor, Federal
ERISA Enforcement Agency, with some annotating notes, to show the
basic idea and a picture of the most complicated ERISA law for 80% of
US health care claims.
ERISA law applies to patients,
healthcare providers, insurance companies and TPA's as well as
employers.
We received numerous comments
and feedbacks on our comprehensive chapters and pages on this web
site, requesting for a simplified "dummy version" ERISA page and a
roadmap of the ERISA basics in health care claim appeals.
We would like to try this
format to find out if we could accomplish this huge task.
Please e-mail your
questions and comments.
Medical Claim Delays & Denials? What Does
an Unanimous
US
Supreme Court
Say?
On June 21, 2004, an unanimous US Supreme
Court ruled that claim processing (medical judgment & benefits
determination) and denials of benefits under the
employer-sponsored health plans,
ERISA-regulated benefit
plans,
for
both self-insured and
fully-insured (through purchase of insurance) health plans,
are completely governed by federal law ERISA, that supersedes and
invalidates state laws.
ERISAclaim.com: "employer-sponsored group health plans"
=
"ERISA-regulated benefit
plans",
both self-insured and
fully-insured (through purchase of insurance) health plans,
(ERISA - Title 29, Chapter 18.
Sec.
1002.)
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ERISAclaim.com -
Supreme Court Managed Care ERISA Watch
Aetna Health Inc. v. Davila
06/21/04
Opinion of the
Court
"Held:
Respondents’ state causes of action fall
within ERISA§502(a)(1)(B), and are therefore completely
pre-empted by ERISA §502 and removable to federal court.
Pp. 4–20."
"We hold that
respondents’ causes of action, brought to
remedy only the denial of benefits under
ERISA-regulated benefit
plans, fall within the scope of, and are completely pre-empted
by, ERISA §502(a)(1)(B), and thus removable to federal
district court. The judgment of the Court of Appeals is
reversed, and the cases are remanded for further proceedings
consistent with this opinion.7
It is so ordered."
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What You Should Know about Filing
Your Health Benefits Claim (Claims Card)
(DOL)
PDF) |
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If you are an employee or family member
of an employee who receives health
benefits from a health plan provided through
employment
in the private sector, a
federal law, the Employee Retirement Income Security Act
(ERISA),
protects you. Among the protections, ERISA sets
standards for administering these plans. Those standards
require plans to give you important information about the
plan and to have a fair process for handling benefit claims.
ERISAClaim.com Notes:
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If you have health insurance
(benefits) from your job in private-sector, you're
covered under ERISA, Employee Retirement Income
Security Act of 1974, the federal law.
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"Protects You": ERISA regulates
and governs your insurance dispute and denial, this
is true for both self-insured and fully-insured
health plans (your employer bought a group insurance
policy).
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ERISA, the federal law, requires
insurance company and HMO to tell you everything
(Information) and ERISA guarantees your rights and
fair processing of your claims and appeal of
denials.
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ERISA, the federal law, instead
of state insurance laws, regulates your health
insurance dispute and denials if you're covered from
private employer sponsored health plans.
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Below are steps you should take to file a
benefit claim and what to do if your claim is denied. It is
especially important to know your rights under your plan and
the law if your benefit claim is denied.
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The first step you should take - even
before you are ready to file a benefit claim - is to
carefully read your plan's summary plan description. This is
a document which your plan administrator must furnish to you
after you join the plan. You can also request a copy from
your plan administrator. The SPD gives you a detailed
summary of your plan - - how it works, what benefits it
provides, and how they may be obtained (the process for
filing your claim). The summary plan description is also
required to describe your rights and protections under
ERISA.
ERISAClaim.com Notes:
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Under ERISA, the insurance policy
is called
SPD, Summary Plan Description, ERISA
version of insurance policy.
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Your employer or anyone in charge
of the health insurance must give you a copy of
SPD
as required by federal law.
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SPD has everything about "what is
covered" or "what is not covered", including
pre-existing condition, deductible, PPO, HMO, and
who is legally responsible for your claim processing
and dispute.
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Many SPD's are publicly available on Union or Company intranet or
website:
1199SEIU National Benefit & Pension Funds - SPDs; US AIRWAYS
SPD.
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If you requested for a copy of
SPD and didn't receive it as specifically required
by ERISA, the entity or individual responsible for
this compliance will be fined for up to $110 per day
by federal court.
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ERISA requires every plan to have
procedures for filing a claim and to tell you what those
procedures are. As noted above, this
information must be included in the summary plan description.
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All plans have rules governing what
benefits they offer and how to apply for them. For example,
some plans may require you to file a claim (seek
authorization) before you can receive medical treatment.
Some plans may have special rules for urgent care. For other
plans, you must submit a claim for reimbursement after
receiving and paying for the care yourself.
ERISAClaim.com Notes:
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ERISA has rules for your health
insurance and for you, it is outlined in a document,
ERISA version of insurance policy,
SPD.
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Insurance companies must follow
these rules and procedures.
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You must also specifically follow
these rules to get your claims paid, and to follow
the steps outlined in SPD if your claims are denied.
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If you can't follow these rules,
you won't get your health care or won't get claims
paid from your insurance.
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To avoid a delay in processing your claim
or a denial of your claim, you should follow the steps
outlined in your plan's summary plan description when filing
your claim. If you cannot find the steps, or if you cannot
understand them, you should consult your plan administrator
or contact the Department of Labor's Employee Benefits
Security Administration (EBSA) for help in understanding
your rights.
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Your plan's claims procedure should state
the time within which the plan must provide you with a
decision on your claim. Be sure to look for these in your
SPD. When you submit a claim to your plan, note the date and
keep track of the time as you wait for a decision. Some
plans may have different time periods depending on the
nature of the benefit claim - such as if the claim is for
urgent care or whether the claim is filed before medical
care is received or after. Some plans' procedures allow the
plan to extend the time period. Your plan's claims procedure
should provide for the plan's notification to you of the
plan's decision on your claim for benefits. If you do not
get a response from your plan within the specified time
period, contact your plan administrator.
ERISAClaim.com Notes:
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ERISA has very specific rules on
timelines your insurance HMO/PPO must follow after
you send your claims.
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Different types of claims require
different timeline for response.
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ERISA
"Promt Pay" timeline
can be found by
clicking here and check below.
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Your plan may deny a claim for many
reasons. For example, you may not have met the plan's annual
deductible, the requested treatment may be something the
plan says is not covered or not medically necessary, or you
may not have filed enough information for the plan
administrator to process the claim. Look for the reason and
other information provided in the notice of denial so that
you can determine if you want to appeal the decision.
ERISAClaim.com Notes:
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You must read carefully specific
reasons your insurance company gave when you receive
denials.
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Usually this type of denial
notice is called EOB in your doctor's office,
Explanation of Benefits.
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Only reasons given and found on
this EOB, Explanation of Benefits, are official and
legal grounds for denial.
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Any payment less than 100%
claimed is considered denial, partial denial or
total denial.
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Your denial notice is extremely
important because it starts the clock ticking on your
appeal rights and legal ground to appeal.
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When you are notified that your claim has
been denied, your plan administrator also must tell you how
to appeal your denied claim for a full and fair review. Your
plan will specify the number of days you have to file your
appeal and may provide for extensions of that time period.
When appealing a benefit denial, be sure to include any
additional information or evidence supporting your claim or
required by your plan's procedure, and get it to the
specified person and address within the permitted time
period.
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Your plan's claims procedure should also
specify the time period for the plan to make a decision on
your appeal. Note the date when you submit your appeal and
be aware of this waiting period. The waiting period for
decisions on appeals may also be different depending upon
the type of claim that was initially filed - such as if the
claim is for urgent care or whether the claim is filed
before the medical care is provided or after.
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When the decision is made on your appeal,
you must be notified of the decision. If your claim is
denied, you must be told the reason and the plan rules upon
which the decision was based in writing in a manner you can
understand. If you do not receive notification of the
decision within the waiting period provided for in your
plan, you can assume your claim has been denied after it was
reviewed.
ERISAClaim.com Notes:
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Health insurance problems under
managed-care are the most frustrating problems faced
by the entire nation, but if you understand ERISA
law and your plan's claims procedure in the SPD, you can
win your most appeals.
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You must understand ERISA appeals
procedure-federal law, every plan and managed-care
organization must follow;
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you must also understand and
follow your individual plan's claims procedure from
that SPD.
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ERISA claims procedure-federal
law is explained in more details by
DOL by clicking here.
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If you disagree with the final decision
on your appeal or if your plan fails to make a timely
decision, you have the right under ERISA to file suit in
court to get your benefits. The plan's explanation of your
denial should describe this right. You also may wish to get
in touch with the Department of Labor's Pension and Welfare
Benefit Administration concerning your rights under ERISA.
ERISAClaim.com Notes:
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If you really understand and
follow ERISA laws, individual plan's claim procedure
and appeal denials appropriately, you may resolve
most of your dispute. Otherwise you can file lawsuit
in federal court.
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ERISA lawsuit successful rate is
mostly depending upon how well you appealed, instead
of lawsuit only.
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Without appropriately completing
your appeals as required by ERISA law and plan's
appeal procedure in a timely fashion, you will most
likely lose in your lawsuit in federal court.
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If your health insurance is in
private-sector and from employment, ERISA, instead
of state insurance law, is the governing Law and
federal court, instead of state court, is the right
place to file lawsuit.
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You must complete ERISA appeals
before filing any lawsuit.
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As noted above, it is important that you
know what your plan's claims process. If you fail to follow
the plan's process, including meeting required deadlines,
your ability to challenge the plan's decision in court could
be affected.
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If your plan's procedures do not give you
the rights provided for under ERISA, or if your plan fails
to follow its procedures, you may have the right to bring an
action in court to enforce your rights.
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For further information on your rights
under ERISA, contact the Employee Benefits Security
Administration's Toll-Free Employee & Employer Hotline at
1.866.444.EBSA (3272).
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Patient's
Rights Claims Procedure Regulation (Fact
Sheet)
(DOL, Department of
Labor) |
Click the above link to DOL for basics of ERISA claim procedure and
ERISA required contents of SPD (Summary Plan
Description, ERISA Version of Insurance Policy)
ERISA Version of Insurance Policy; Master Copy for
"Insurance Verification" Must include the Following
Information:
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The final regulation
updates and clarifies certain summary plan description
content requirements for ERISA-covered employee
benefit plans. |
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The SPD content
regulation implements the information disclosure
recommendations of the President’s Advisory Commission
by clarifying the information required to be disclosed
to plan participants and beneficiaries, in or as part
of, the plan’s summary plan description, and updates
the disclosure rules applicable to both pension and
welfare benefit plans. The SPD content regulation:
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Provides that
health plan SPDs must describe:
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Any cost-sharing
provisions, including premiums,
deductibles, coinsurance and
copayment amounts for which the participant or
beneficiary will be responsible
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Any annual or
lifetime caps or other
limits on benefits under the plan
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The extent to which preventive
services are covered under the plan
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Whether, and
under what circumstances,
existing and news drugs are covered under the plan
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Whether, and
under what circumstances,
coverage is provided for medical tests, devices
and procedures |
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Provisions
governing the use of network
providers, the composition of the provider network
and whether, and under what circumstances,
coverage is provided for out-of-network services
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Any conditions
or limits applicable to
obtaining emergency medical care
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Any provisions
requiring preauthorization
or utilization review as a condition to obtaining
a benefit or service under the plan.
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Requires that the
SPDs of pension and welfare benefit plan describe,
among other things, the procedures on qualified
domestic relation orders (QDROs) and qualified
medical child support orders (QMCSCOs),
the plan sponsor’s authority
to terminate the plan or eliminate benefits under
the plan, COBRA continuation rights, and
updated information on coverage by the Pension
Benefit Guaranty Corporation and ERISA rights.
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Repeals the
limited exemption relating to SPDs of health plans
that provide benefits through qualified health
maintenance organizations (HMOs). Thus, health plans
that provide benefits through a federally qualified
HMO must comply with the improved SPD disclosure
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Adopts in final form
regulations implementing amendments to
ERISA made by the Newborns' and
Mothers' Health Protection Act. The final
regulation requires health plan
SPDs to include information on requirements under
federal or state law applicable to the plan, and any
health insurance coverage offered under the plan,
relating to hospital length of stay following newborn
deliveries.
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Your telephone
verification always has a DISCLAIMER, but SPD can not
disclaim for peace of your mind, as SPD is statutorily
required to be distributed to every plan participant as a
plan controlling document.
If you really
want to know for "legally" sure, what is or isn't covered
under your plan, with out "if" and "but", you should do as
DOL, federal ERISA enforcement agency suggested:
"The first step you should take - even
before you are ready to file a benefit claim - is to
carefully read your plan's summary plan description.
This is a document which your plan administrator must
furnish to you after you join the plan."
What You Should Know about Filing (DOL)
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Want to know more
and get smarter on this SPD rule?
Amendments to Summary
Plan Description Regulations
(Final Rule) - New SPD Laws with more
protections.
ERISA 2520.102-3 Contents of Summary Plan Ddescription.
- Complete SPD laws in ERISA Regulation.
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But, now you read
your Plan's SPD, ERISA version of Insurance Policy, and
got a lot of claim delays and denials even you did exactly
as they told you on every thing, and made tons of phone
calls to your
state insurance department or
commissioners, and
insurance companies as well as so many middlemen, you were
told they go by ERISA rules, not your state insurance
laws. You are mad as hell and very frustrated.
Are they right as
bad as they are to you?
If you got this health
insurance from work in private sectors - "ERISA protects
you", still remember it?, you
need to find out Rules governing your dispute, ERISA Claim
Regulation.
Check out these
rule to see if your insurance people (insurance, HMO, TPA,
fiduciary and plan administrator) have followed any or
none of these rules to make you so mad.
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Patient's
Rights Claims Procedure Regulation (Fact
Sheet)
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