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ERISA Appeal 1-2-3
A Guide from DOL
with "Dummy Annotations"
© 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:
-
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.
-
"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).
-
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.
-
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:
-
Under ERISA, the insurance policy
is called
SPD, Summary Plan Description, ERISA
version of insurance policy.
-
Your employer or anyone in charge
of the health insurance must give you a copy of
SPD
as required by federal law.
-
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.
-
Many SPD's are publicly available on Union or Company intranet or
website:
1199SEIU National Benefit & Pension Funds - SPDs; US AIRWAYS
SPD.
-
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:
-
ERISA has rules for your health
insurance and for you, it is outlined in a document,
ERISA version of insurance policy,
SPD.
-
Insurance companies must follow
these rules and procedures.
-
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.
-
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:
-
ERISA has very specific rules on
timelines your insurance HMO/PPO must follow after
you send your claims.
-
Different types of claims require
different timeline for response.
-
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:
-
You must read carefully specific
reasons your insurance company gave when you receive
denials.
-
Usually this type of denial
notice is called EOB in your doctor's office,
Explanation of Benefits.
-
Only reasons given and found on
this EOB, Explanation of Benefits, are official and
legal grounds for denial.
-
Any payment less than 100%
claimed is considered denial, partial denial or
total denial.
-
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:
-
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.
-
You must understand ERISA appeals
procedure-federal law, every plan and managed-care
organization must follow;
-
you must also understand and
follow your individual plan's claims procedure from
that SPD.
-
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:
-
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.
-
ERISA lawsuit successful rate is
mostly depending upon how well you appealed, instead
of lawsuit only.
-
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.
-
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.
-
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
rule. |
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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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Faster decisions on initial
claims - rather than 90 days (or more) under
current regulation, the new rule would require
decisions (in most cases) not later than:
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72 hours for urgent care claims
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15 days for pre-service claims
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30 days for post-service claims
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One 15 day extension for pre- and
post-service claims |
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Faster decisions on
appeal of denied claims
- rather than 60 days
(or more) under current regulation, the new rule
would require decisions (in most cases) not later
than:
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72 hours for urgent care claims
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30 days for pre-service claims
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60 days for post-service claims
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Claimants have
more time to file appeals
- 180 days, rather than
current 60 days.
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If
treating physician
determines the claim is “urgent,” plans
must treat as urgent. |
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Plans
cannot impose fees or
costs as a condition to filing or
appealing a claim. |
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Arbitration
permitted, but only with
full disclosure regarding the process,
arbitrator, relationships, right to
representation, and only if claimant agrees
after completing internal appeal. |
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Review must be de novo.
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Decision maker
on appealed claims must be
different than the person deciding initial
claim. |
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Plans must
consult with appropriate
health care professionals in deciding appealed
claims involving medical judgment.
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Plans may not
require more than two
levels of review of denied claims. If
more than one level, both levels must be
completed within time frame applicable to one
level. |
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Special rules
for the continuation or extension of approved
benefits or services to be provided over time
(“concurrent care decisions”). Individuals
receiving approved care over a period of time
must have an opportunity for review before
benefits are reduced or terminated. Also, urgent
care requests for an extension of approved
benefits must be decided within 24 hours.
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Plans must
have procedures and safeguards for ensuring and
verifying consistent
decision making. |
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Plans must
notify claimant of
defective filing of claim in case of pre-service
claims.
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If plans fail
to make timely decisions or otherwise fail to
comply with the regulation,
claimants may go to court
to enforce their rights. |
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Plans must provide
participants a full description of the
plan’s claim procedures. |
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Plans must
provide specific reasons
for denials, including identification of and
access to any guidelines, rules, protocols
relied upon in making the adverse determination.
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Plans must
provide participants
access to all documents, records and other
information relevant to the benefit
determination, without regard to whether the
plan relied on the material. |
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Plans must
disclose the name of
medical professionals consulted as part of the
claims process. |
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Patient's
Rights Claims Procedure Regulation (Fact
Sheet) |
The ERISA rule
requires those people handling your insurance claims and
appeals, fiduciary, to be nice and fair to you, do things
fast for you and hold no secretes from you. If they
followed ERISA rules,
you shouldn't get mad, if not, appeal by these rules, or "If
plans fail to make timely decisions or otherwise fail to
comply with the regulation,
claimants may go to court to enforce their rights."
(what part of the laws said this?)
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Now, you
kind of like this ERISA rules, want to know more?
New
Federal Claim Regulation (Final Rule) - New
Rules for Claims Dispute
ERISA
2560.503-1 Claims procedure -
Complete ERISA Regulation on Claims Dispute.
Title 29 U.S.C. § 1141 states:
"It shall be unlawful for any
person through the use of fraud, force, violence, or threat of
the use of force or violence, to restrain, coerce, intimidate,
or attempt to restrain, coerce, or intimidate any participant or
beneficiary for the purpose of interfering with or preventing
the exercise of any right to which he is or may become entitled
under the plan, this title, section 3001, or the Welfare and
Pension Plans Disclosure Act. Any person who willfully violates
this section shall be fined $10,000 or imprisoned for not more
than one year, or both. The amount of fine is governed by 18
U.S.C. § 3571. The U.S. Sentencing Guidelines address 29 U.S.C.
§ 1141 under the guidelines for "Fraud and Deceit" (U.S.S.G. §
2F1.1) or for "Extortion by Force or Threat of Injury or Serious
Damage (U.S.S.G. § 2B3.2)......"
"For example, Section 1141
would reach the use of deception directed
at misleading a welfare plan beneficiary as to the amount of
health benefits owed to the beneficiary under the terms of the
plan or at misleading a pension plan participant as to
the amount of retirement benefits to which he would become
entitled under the plan upon his retirement."
ERISA in the United States Code
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You do
like these lovely laws, but they are too hard for you to
understand.
Don't worry, Uncle Sam (DOL)
knew you may NOT be that smart to get these, they made these
Frequently Confused/Asked Questions and Good/Smart answers, DOL
FAQ, ERISA, for people like you.
But we think Uncle SAM is
not that smart either, ERISAclaim.com and Dr. Jin Zhou, made this
ERISA Time Chart and package Bundle, "ERISA Power Guides", to pack
the good ERISA stuff for you to get smart on ERISA laws and rules,
to go along with Uncle SAM (DOL) ERISA FAQ.
Oh, by the way, as mad as
you are,
after 143 million Americans and
950,000 doctors sued almost every insurance companies in federal
court,
Aetna and Cigna got
smart to settle with 950,000 doctors while 143 million Americans
were told by federal court to go back to get ERISA appeals or
finish ERISA appeals,
we got hold of
these Aetna and Cigna Settlements. and surprised to learn: ERISA
Settlements.
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Benefit Claims Procedure Regulation
(FAQ) (DOL)
ERISA Rules
for Every One |
For patients and their doctors, insurance companies, HMO, PPO
and TPA's as well as employers, ERISA law applies to all of you
when you deal with ERISA claims, health insurance from job in
private sectors.
Although ERISA protects
doctors, but not directly without patient's specific
authorization, to name the doctor as the patient personal
"authorized representative". Once the doctor/provider complied
with ERISA claim procedure, you will have the same rights as
your patient has under ERISA, such as getting a copy of SPD, fee
schedules (UCR), reviews secretes/guidelines (DOL
FAQ, B2 & B3), and
right to sue in federal court, not
only for medical claims, but also for
SPD penalty ($110/day).
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Benefit Claims Procedure Regulation
(FAQ) (DOL)
Click above
for complete official document
 |
No. An assignment of benefits by a claimant
is generally limited to assignment of the claimant’s right to
receive a benefit payment under the terms of the plan.
Typically, assignments are not a grant of authority to act on a
claimant’s behalf in pursuing and appealing a benefit
determination under a plan. In addition, the validity of a
designation of an authorized representative will depend on
whether the designation has been made in accordance with the
procedures established by the plan, if any.
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Nothing in the regulation precludes a plan
from communicating with both the claimant and the claimant’s
authorized representative. However, it is the view of the
department that, for purposes of the claims procedure rules,
when a claimant clearly designates an authorized representative
to act and receive notices on his or her behalf with respect to
a claim, the plan should, in the absence of a contrary direction
from the claimant, direct all information and notifications to
which the claimant is otherwise entitled to the representative
authorized to act on the claimant’s behalf with respect to that
aspect of the claim (e.g., initial determination, request for
documents, appeal, etc.). In this regard, it is important that
both claimants and plans understand and make clear the extent to
which an authorized representative will be acting on behalf of
the claimant.
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ERISA “Prompt Pay”
Time Limits
© 2003 - 2004 Jin Zhou, ERISAclaim.com
|
ERISA §2560.503-1
Claims Procedure
|
New Rules
Effective
on 01/01/2003 for all ERISA plans
self-insured and fully-insured,
§2560.503-1(a) |
Old Rules |
|
Urgent Care Claim |
Preservice Claim |
Post-Service
Claim |
Disability Claims |
ERISA Claims |
|
Claim Beginning
Time |
Beginning at a Time a Claim Is Filed,
Regardless of Clean Claim or Not, In Accordance With Plan
Procedures,
§ 2560.503-1(f)(4) |
|
Decision Maximal
Time Limits |
In No Event
Exceeding 90 Days Period,
§2560.503-1(f) |
< 180 days |
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"Not Clean"
Notification Time |
24 hours |
5 days |
N/A |
N/A |
N/A |
|
Claimant Claim
Cleanup Time |
48 hours |
45 days |
45 days |
45 days |
N/A |
|
Plan Initial
Determination |
ASAP,
<48 hours (clean claim)
< 72 hours (cleaned up claims)
|
15 days |
30 days |
45 days |
90 days
|
|
Claimant Appeal
Deadline |
180 days |
180 days |
180 days |
180 days |
60 days |
|
Plan 1st Level
Appeal Response Time |
72 hours
|
15 days |
30 days |
45 days |
60 days |
|
Plan 2nd-Level
Appeal Response Time |
15 days |
30 days |
90 days |
120 days with
extensions |
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Plan Extension
Time |
48 hours |
15 days |
15 days |
75 days |
120 days |
|
Review/Appeal
Maximal Limit |
72 hours |
30 days (one
Appeal)
15 days (two
appeals) |
30 days (two
appeals)
60 days (one Appeal) |
105 days |
180 days |
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Initial
Determination/EOB by: |
"The Plan Administrator",
§ 2560.503-1(g) |
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Appeal Delay &
Denial to: |
"An Appropriate Named Fiduciary of the
Plan",
§ 2560.503-1(h) |
|
Review/Appeal
Decision by: |
"The Plan Administrator",
§ 2560.503-1(j) |
|
|
For more basics of ERISA,
click here to
"ERISA Demystied"
For Professional Turn-key
appeal Book and Systems, click here for
Appeal
Book From ERISAclaim.com.
Free 2004 Update "ERISA
Assigment Dispute"
(09/16/2004)
Discount for
March 2005: $35
$450 ERISA CD
Book
Click here or the CD-Picture
to enter our Secured Online Order page
Click here or the CD-Picture
to enter our Secured Online Order page
You may also attend our monthly ERISA Seminars
for
more hands on trainings:
|
U.S. Health-care Crisis & ERISA Criminal Enforcement
950,000 MD's Settled With
Aetna & Cigna on ERISA
|
Brief Summary Of
the
New Regulation
for Physicians and
ERISA Plans/TPAs |
|
Effective Date: January 01, 2003 |
|
For
Physicians and Health-care Providers |
For
Insurance Companies
ERISA Plans/TPAs |
|
ERISA's
Prompt Pay Law, better than State Prompt Pay Laws
[29 CFR § 2560.503-1
(f)(i),
Page 70267-9] |
ERISA's
Prompt Pay Law, better than State Prompt Pay Laws
[29 CFR § 2560.503-1 (f)(i), Page 70267-9] |
| |
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New Assignment of Benefit Form Required for
Appeals and Claim Dispute
(DOL
FAQ, B2-B3) |
No New Legal Assignment of Benefit Form, No
Obligations to Physicians and Health-care Service Providers
(DOL
FAQ B2),
otherwise Obligations to Disclose to Both Patients and Providers
(DOL FAQ B-3) |
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No written appeal, no rights, except for claims
involved with urgent care.
[Page 70255 & 70271] |
In claims involved with urgent care,
physicians/health-care providers are to be considered by default as
authorized representatives.
[Page 70255 & 70271] |
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The regulation clarifies for the first time since 1977 and
prohibits anti-assignment provisions in ERISA plans & (footnote 36).
[page 70255 ]
[29 CFR § 2560.503-1 (b) (4) Page 70266] |
Assignments by patients must be absolutely
clear as to what extent and capacity, verifications are permitted &
(footnote 36).
(DOL FAQ B-3)
[page 70255 & 70266]
[29 CFR § 2560.503-1 (b) (4), Page 70266] |
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Must complete required two levels of appeals,
with legal assignment of benefits and specific written request for
disclosure of specific plan documents.
[Page 70253] |
No legal assignment of benefits, no response
required; no specific written request, no disclosure obligated,
however failure to establish and comply with claim procedures,
administrative remedies are considered to be exhausted. Lawsuit may
follow.
[Page 70271] |
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New protections for pre-service claims and
urgent care claims against improper pre-authorization,
pre-certification and utilization review as well as urgent cares.
[Page 70248 & 70271] |
Understanding of differences in pre-service,
urgent care and post-service claims will save big money in fiduciary
breach liability claims and POSSIBLE
medical malpractice claims. [Page
70248 & 70271] |
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New definitions of relevant documents and
disclosure obligations, no more medical necessity secrets, UCR fee
schedule confidential
[Page 70252]
[29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271]
[DOL FAQ B-5] |
No legal assignment of benefits, no obligation
to disclose to an assignee, assignment verification by the plan is
allowed and protected.
Update SPD and any guidelines, only use disclosable and
qualified medical claim reviewers.
[Page 70252]
[29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271]
[DOL FAQ B-5] |
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A Full and Fair Review with new definitions and
protection requires de novo reviews on two appeals by at least four
different people, two different fiduciaries with ERISA plan, and
two different Health-care professionals independent to the ERISA
plan.
[29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271]
[Page 70252-70253] |
Update
SPDs with New Standards and compliance, specify and designate
only qualified fiduciaries for appeals, establish new complaint
appeal procedures, use only disclosable and licensed as well as
certified health-care professionals for medical reviews,
pre-certification and prior authorizations in every case.
[29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271]
[Page 70252-70253] |
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New clarifications on state law preemptions and
"independent" medical reviews. No preemption for state laws unless
prevention of the application of the new regulation
[Page 70254] |
Comply with both
the regulation and state laws in claims involving mixed
treatment and eligibility determinations and pure medical treatment
decision-makings.
[Page 70254] |
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New clarifications with new definitions claim
denial/an adverse benefit determination (payment<100% claimed)
or Overpayment, and new protections.
(DOL FAQ C-12) |
Overpayment vs. an adverse benefit
determination, recoupment vs. appeal procedures.
(DOL FAQ C-12) |
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SPDs must
describe...... |
No SPDs, No
decision making |
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Insurance company's decision-making power and
disclosure obligations must be described in SPD
[29 CFR 2520.102-3 (q), Page 70242] |
Fully-insured plans with a health insurance
issuer being wholly or partially responsible for administering the
plan (e.g. payment of claims) must describe insurer's role in SPD.
[29 CFR 2520.102-3 (q), Page 70242] |
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Claim fiduciary, whoever makes denial
appeal decisions, has duties to disclose
SPD and relevant document
[29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] or may face up to $110 a day penalty under "Prudent Actions by Plan
Fiduciaries" and "Enforce Your Rights."
[29 CFR § 2520.102-3, Page 70243] |
Claim fiduciaries or plan fiduciaries
have new duties to disclose, without charge,
SPD and relevant
document
[29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] when claim for
benefits is denied or delayed, or may face up to $110 a day penalty
under "Prudent Actions by Plan Fiduciaries" and "Enforce Your
Rights."
[29 CFR § 2520.102-3, Page 70243] |
|
Failure to timely
make benefit determination and review decisions by the plan
administrator will constitute "deemed denied" review/appeal and
"deemed exhaustion of administrative remedy" under
§ 2560.503-1(l), ("a decision on the
merits of the claim" = de novo judicial review, instead of
deferential judicial review) that will forfeit or preclude
the plan from "deferential review standard" on judicial review in
federal court,
the most important part of "ERISA Shield" on ERISA land.
Gilbertson v Allied Signal Inc |
DOL interprets
§
2560.503-1(l) through CFR accompanying supplementary information on
page 70255: “The Department’s intentions in including this
provision in the proposal were to clarify that the procedural
minimums of the regulation are essential to procedural fairness and
that
a
decision made in the absence of the mandated procedural protections
should not be entitled to any judicial
deference.” |
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More.... |
More.... |
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More.... |
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And
many more new and
important
provisions and protections for health-care providers and
insurance companies/ERISA plans/TPA's, as well as patients and
employers. |
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Kaiser statehealthfacts.org
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Due to the recent demand
from the
ERISA plans and TPA's, we're pleased to announce
that we also provide educational and consulting services to the ERISA plans,
TPA's and managed care organizations on
New
Federal Claim/ERISA Regulations and
Compliance, however we do not provide any services involving actual claim
dispute or legal advice for any legal matter or disputes. |
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Codified in Title 29 of the
Code of Federal Regulations:
Regulations
Selected links:
2520.102-3 Contents of summary plan description.
2560.503-1 Claims procedure. |
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ERISA Laws/Rules
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DOL
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HIPPA Final
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$10,600 ERISA Claim
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| Recent Federal Court Ruling in a Case with
$10,600 medical claim, insurance Co. refused to pay, provider
made numerous demand for payment in almost one year, but no
appeals filed, the court dismissed the lawsuit because provider
failed to exhaust administrative remedy, as required under ERISA,
by filing ERISA claim appeals. This situation is so popular
in health-care community.
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$37,350 ERISA Claim
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| Health-care provider alleged medical claims
submitted to Aetna for reimbursement, Aetna asserted no receipt
of medical claims, no written denials. Health-care
provider failed to present proof of claim submission, claim
denial and ERISA claim appeals. This case was dismissed. ERISA
health-care claims are handled in federal court, state law is
generally not applicable.
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Opinion: Cutting Costs in Half Through Better Management is
Fantasy But Health Care Debate Is Real (The Hartford
Courant)
Excerpt: "If a
talk on economics can have a $650 billion throwaway line,
Treasury Secretary Paul O'Neill delivered it.... "
"O'Neill
insists the problem is not with people, but systems - systems
that invite medical errors, systems that penalize health care
professionals for making honest mistakes, systems that create
the mind-numbing complexity of reimbursement for providers,
systems that reward too much treatment and punish efficiency." |
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ctnow.com
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Health
Cost Trends Shift
"The study said managed care probably has squeezed out all the
savings it can from the nation's health care system and that
employers are turning to other familiar devices such as
increasing premiums and co-payments to trim their costs" |
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