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Moukawsher & Walsh, LLC
Pension and Employee Benefit Law

Benefitlawyers.com

 
 

Pomerantz Haudek Block Grossman & Gross LLP ("PHBG&G")

ERISA and Healthcare-Related Class Actions

SPD's for FEHB

Federal Employees Health Benefit Plan

 

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Links to Plan Brochures for 2003

 

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ERISAclaim.com - 2009 - 2010 Claim Denial & Overpayment Dispute Two-day ERISA Appeal Seminars,

 

ERISAclaim.com - 2010 ERISA Claim Specialist Certification Programs in Chicago, Illinois

 

New ERISA Appeal Book with 2010 Major Updates  $450  & $150 (Updates only with previous purchase)

 

ERISAclaim.com - ERISA Litigation Support, Facts + Laws + Strategies = Winning Lawsuit When Inevitable

 

ERISAclaim.com - Free ERISA Webinar, The Beginning for $6 Trillion Healthcare Denial Management Market

 

2006 Reimbursement Seminars

Problem Oriented ERISA & Medicare Claims

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Click above for 2006 Seminars

 

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Click The State Name for Time, Location & Agenda of Each Seminar

Seminar Schedules in IL NC, PA, VA, OH, SD, Teleconference

 

The Virginia Society of Chiropractic

Presents

 

Stop Managed Care Abusive Claim Delays & Denials!

Getting Paid by Compliance with New Federal Claim (ERISA) Rules  

The Most Powerful & only Seminar in the U.S.
on Health Care
ERISA Claim Denials & Appeals

 

7 hours of CE Type 1 Hours pending through
Sherman College of Straight Chiropractic

 

 

Sponsored by the VSC and insurance relations committee.

Co-sponsored by the ICA.

 

Call (888) 639-4872 for more information

 

"If you have EVER been denied a claim for 'necessity' or had even 1 claim reduced based on mythical 'UCR's', you need to be at this program" 

 

v     Take this unique opportunity to bullet-proof your insurance collections with Expert Knowledge of Federal ERISA Law.

v     You’ll get Unprecedented Information to help you properly appeal your claims.

v     Join the growing ranks of Chiropractic offices that are willing to fight back for proper and fair payment for the services that they render.

 

This powerful and unprecedented program of handling insurance appeals will provide you not only with vital new protection from the NEW FEDERAL REGULATIONS, but also the best techniques in performing legally effective appeals that get results.  This unique program is the first and only program in the country that teaches doctors and their staff how to use existing ERISA laws in their claim procedures.  Most doctors have been hopeless victims of insurance denials by ERISA. Let us teach you how to turn the table to your advantage.

 

Saturday, July 13th

9:00 – 6:00 P.M.

Location:      Holiday Inn/Crossroads- Richmond, VA
2000 Staples Mill Road   (804) 359-6061

Pre-Registration:

VSC/ICA Members

$99

 

Non-Members        

$150

 

Additional Staff Member

$50

 

 Up to 3 Staff

$75

Late Registration:

After July 5th

add $50

 

Name:                                            Office Name:

Address:                             City Name:                                  Zip Code:

 

Phone #:                        Fax #:                              E-Mail:

2002 VSC/ICA Member        Non-Member      Staff             Total Amount


(Checks made out to VSC)


Visa/Mastercard                                                          Exp. Date:

 


Signature                                                                        Staff Name(s)

 

 

Please Fax Information: (540) 769-0128 or

Mail to: VSC, 908 Colorado Street, Salem, VA  2415

Call (888) 639-4872 for more information

 Why ERISA Seminars for Health-care Providers???

Virginia Protections

RUSH PRUDENTIAL HMO, INC. v. MORAN [00-1021]

U.S. Supreme Court, Decided June 20, 2002

 

SUPREME COURT ALLOWS ILLINOIS STATUTE REQUIRING HMO TO PROVIDE INDEPENDENT MEDICAL REVIEW ON DEMAND

Excerpt (from unofficial syllabus): 'The Illinois HMO Act is directed toward the insurance industry, and thus is an insurance regulation   under a commonsense view.... Congress recognized, the year before passing ERISA, that HMOs are risk-bearing organizations subject to state insurance regulation. That conception has not changed ..." (U.S. Supreme Court)

 

Selected Laws from the Code of Virginia Department of Health

Selected Sections from Chapter 5, Title 32.1 Health

Peer Review Agents.

 

 

Virginia Patients' Rights:
External Review 2000
50 State Comparisons:

Virginia Yes Applies to any health plan.
Type of Grievance: Any denial of services.
Filing Time Limit: None.
Filing Fee: $50.
State Authority: The Bureau of Insurance.
Other Requirements: Minimum loss $300.

Virginia State Recognition of URAC Accreditation
Virginia
-Health Network
-Health Plan
-Health UM

Requirement for compliance with the Health Utilization Management Standards of the American Accreditation healthcare Commission (URAC), URAC Version 3 (pdf)

Code of Virginia   Title 38.2 - INSURANCE.

Chapter 58 Managed Care Health Insurance Plans (38.2-5800 thru 38.2-5811)
Chapter 59 Independent External Review of Adverse Utilization Review Decisions (38.2-5900 thru 38.2-5905)

Virginia Administrative Code
Searchable database.

12VAC5-408-360. Utilization review and management.
Virginia Administrative Code search result for Utilization Review
bullet 12VAC30-10-530 (show hits) ..Utilization and quality control.. (1)
bullet 12VAC30-10-650 (show hits) ..Drug Utilization Review Program.. (2)
bullet 12VAC30-120-115 (show hits) ..Reevaluation requirements and utilization review.. (3)
bullet 12VAC30-120-180 (show hits) ..Personal care services.. (1)
bullet 12VAC30-120-190 (show hits) ..Respite care services.. (1)
bullet 12VAC30-120-210 (show hits) ..Definitions.. (1)
bullet 12VAC30-120-220 (show hits) ..General coverage and requirements for home and com.. (1)
bullet 12VAC30-120-250 (show hits) ..Reevaluation of service need and utilization revie.. (3)
bullet 12VAC30-120-30 (show hits) ..General conditions and requirements for all home a.. (1)
bullet 12VAC30-120-330 (show hits) ..Utilization review.. (1)
bullet 12VAC30-120-40 (show hits) ..Adult day health care services.. (3)
bullet 12VAC30-120-400 (show hits) ..Quality Control and Utilization Review.. (2)
bullet 12VAC30-120-480 (show hits) ..Reevaluation of service need and utilization revie.. (1)
bullet 12VAC30-120-50 (show hits) ..Personal care services.. (2)
bullet 12VAC30-120-520 (show hits) ..Personal attendant services (PAS).. (2)
bullet 12VAC30-120-60 (show hits) ..Respite care services.. (2)
bullet 12VAC30-120-700 (show hits) ..Definitions.. (1)
bullet 12VAC30-120-766 (show hits) ..Personal care services.. (1)
bullet 12VAC30-120-768 (show hits) ..Respite care services.. (1)
bullet 12VAC30-120-770 (show hits) ..Consumer-directed services: attendant care, compan.. (1)
bullet 12VAC30-120-780 (show hits) ..Reevaluation of service need and utilization revie.. (1)
bullet 12VAC30-130-130 (show hits) ..Long-stay acute care hospital requirements.. (16)
bullet 12VAC30-130-260 (show hits) ..Appeals.. (1)
bullet 12VAC30-130-270 (show hits) ..Definitions.. (5)
bullet 12VAC30-130-290 (show hits) ..Scope and purpose.. (2)
bullet 12VAC30-130-370 (show hits) ..Medical quality assurance for nursing facility res.. (1)
bullet 12VAC30-130-380 (show hits) ..Definitions.. (3)
bullet 12VAC30-130-390 (show hits) ..Scope.. (2)
bullet 12VAC30-130-400 (show hits) ..Utilization review process.. (1)
bullet 12VAC30-130-410 (show hits) ..Drug Use Review Committee.. (1)
bullet 12VAC30-130-42 (show hits) ..Service limitations.. (1)
bullet 12VAC30-130-800 (show hits) ..Definitions.. (1)
bullet 12VAC30-130-890 (show hits) ..Plans of care; review of plans of care.. (1)
bullet 12VAC30-140-570 (show hits) ..Utilization control.. (1)
bullet 12VAC30-20-110 (show hits) ..Nursing facility resident drug utilization review.. (8)
bullet 12VAC30-50-200 (show hits) ..Physical therapy and related services.. (1)
bullet 12VAC30-50-229.1 (show hits) ..School health services.. (2)
bullet 12VAC30-60-120 (show hits) ..Utilization control: Intensive physical rehabilita.. (1)
bullet 12VAC30-60-130 (show hits) ..Hospice services.. (2)
bullet 12VAC30-60-140 (show hits) ..Community mental health services.. (1)
bullet 12VAC30-60-147 (show hits) ..Substance abuse treatment services utilization rev.. (1)
bullet 12VAC30-60-150 (show hits) ..General outpatient physical rehabilitation service.. (2)
bullet 12VAC30-60-160 (show hits) ..Utilization review of case management for recipien.. (1)
bullet 12VAC30-60-170 (show hits) ..Utilization review of treatment foster care (TFC).. (1)
bullet 12VAC30-60-21 (show hits) ..Utilization control of nonparticipating out-of-sta.. (1)
bullet 12VAC30-60-30 (show hits) ..Utilization control: Long-stay acute care hospital.. (2)
bullet 12VAC30-60-40 (show hits) ..Utilization control: Nursing facilities.. (1)
bullet 12VAC30-60-70 (show hits) ..Utilization control: Home health services.. (1)
bullet 12VAC30-90-272 (show hits) ..Indirect patient care operating costs.. (2)
bullet 12VAC5-405-100 (show hits) ..Access to and confidentiality of medical records a.. (2)
bullet 12VAC5-405-120 (show hits) ..Examination of private review agents.. (1)
bullet 12VAC5-405-30 (show hits) ..Scope.. (4)
bullet 12VAC5-405-40 (show hits) ..Definitions.. (9)
bullet 12VAC5-405-50 (show hits) ..Certificates to perform utilization review.. (2)
bullet 12VAC5-405-70 (show hits) ..Minimum qualifications of staff.. (3)
bullet 12VAC5-405-80 (show hits) ..Adverse decisions.. (1)
bullet 12VAC5-408-10 (show hits) ..Definitions.. (13)
bullet 12VAC5-408-160 (show hits) ..Management and administration.. (2)
bullet 12VAC5-408-350 (show hits) ..Quality assurance program.. (1)
bullet 12VAC5-408-360 (show hits) ..Utilization review and management.. (22)
bullet 14VAC5 (show hits) ..STATE CORPORATION COMMISSION, BUREAU OF INSURANCE.. (1)
bullet 14VAC5-200-60 (show hits) ..Policy practices and provisions.. (1)
bullet 14VAC5-215 (show hits) ..RULES GOVERNING INDEPENDENT EXTERNAL REVIEW OF FIN.. (2)
bullet 14VAC5-215-10 (show hits) ..Scope and purpose.. (5)
bullet 14VAC5-215-100 (show hits) ..Payment of fees.. (2)
bullet 14VAC5-215-110 (show hits) ..Standards, credentials, and qualifications of the.. (2)
bullet 14VAC5-215-20 (show hits) ..Evidence of coverage forms.. (1)
bullet 14VAC5-215-30 (show hits) ..Definitions.. (8)
bullet 14VAC5-215-50 (show hits) ..Appeals.. (13)
bullet 14VAC5-215-60 (show hits) ..Impartial health entity.. (1)
bullet 14VAC5-215-70 (show hits) ..Standard review.. (11)
bullet 14VAC5-215-80 (show hits) ..Expedited review.. (4)
bullet 14VAC5-215-90 (show hits) ..Reconsideration of final adverse decision.. (5)
bullet 14VAC5-234-50 (show hits) ..Minimum standards for benefits for the Essential B.. (1)
bullet 14VAC5-234-60 (show hits) ..Minimum standards for benefits for the Standard Be.. (1)
bullet 16VAC30-50 (show hits) ..RULES OF THE VIRGINIA WORKERS' COMPENSATION COMMIS.. (1)

 

Seminar Schedules in IL NC, PA, VA, OH, SD, Teleconference

Associations for Physicians, Hospitals, Health-care Providers

We are willing to work with any associations with your co-sponsorship and significant discount for tuitions and reference books. You may e-mail or telephone for more details.

$10,600 ERISA Claim

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 ERISAclaim appeals.  This situation is so popular in health-care community.

 

 

$37,350 ERISA Claim

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.

 

 

 

 

 

 

Peer Review

 

 

Statutes (United States Code) 
ERISA - Title 29, Chapter 18. 

        Selected links:

Sec. 1002.
Definitions

Sec. 1003.
Coverage

Sec. 1022.
Summary plan description
Sec. 1104.
Fiduciary duties

Sec. 1140.
Interference with protected rights

Sec. 1141.
Coercive interference

part 7
group health plan requirements

 

 

Code of Federal Regulations

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.

 

 

 

Seminar Schedules in IL NC, PA, VA, OH, SD, Teleconference

 
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