FAQ

Our Certified PPACA ERISA Medical Claims Appeals Specialists have over a decade of experience in appealing denied claims under ERISA rules and regulations.  In addition, we have become a national leader in the claims appeals process by participating in the nation's first PPACA Claims Appeals Certification program. Learn More

1. A denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit.  A denial can occur if a claim that is not paid at all or only in part.  A refusal to pre-certify or pre-authorize a service or procedure is also a denial. A denial can occur if a claim is denied in total or in part. A refusal to pre-certify or pre-authorize a service or procedure is also considered a denial.
2. A denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from the application of any utilization review.  This includes any post payment or retroactive denial, such as a request for the refund of an overpayment or any “recoupments/refunds/offsets.”
3. A failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.  This means any anything that is not paid on the grounds that it is not medically necessary or experimental and investigational.This covers claims that are denied because they are deemed medically unnecessary, experimental or investigational.

Yes.  Federal law requires each plan to guarantee “full and fair review” of denied benefit claims.

A simple request for “documentary information” is not an appeal.  Appeals must be submitted according to the individual health plan documents and must request for a “full and fair” review of the denied claim.  This means the appeal has to conform to the patient’s health plan documents as established in the summary plan description (or SPD). 

Summary Plan Description. ERISA provides that every employee welfare benefit plan must be established and maintained according to a written document. ERISA also requires that the SPD (summary plan description) must provide participants with an accurate and comprehensive summary of the plan. 

Beneficiaries or participants and anyone that is properly assigned. A patient can appeal or designate an authorized representative, such as a provider or facility for example, to appeal on his/her behalf. (iii) Claimant. Claimant means an individual who makes a claim under this section. For purposes of this section, references to claimant include a claimant’s authorized representative. [Federal Register, Page 43355]

Health plans must “provide claimant at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination.” This means that you can appeal a claim within 180 days of denial.  However, there can be exceptions based on the uniqueness of each claim.

ERISA is the Employee Retirement Income Security Act.  This law governs all employer- sponsored benefits.  The Secretary of Labor has primary authority for Title I of ERISA to enforce uniformity of ERISA regulations and beneficiaries’ protections. With few exceptions, most health plans must follow the rules and regulations of ERISA.

Patient Protection and Affordable Care Act, otherwise known as Affordable Care Act or Healthcare Reform Bill, which was upheld by the Supreme Court in June 2012.  This law expanded ERISA rules and regulations with respect to health care.

Yes.  It is well established that a healthcare provider may acquire derivative standing by obtaining a written assignment from a “participant” or “beneficiary” of his right to “stand in the shoes” of the patient.  Additionally, assignee medical providers may challenge benefit denials through the claims process. This means a provider or facility, which is properly authorized as an assignee, can appeal--even if it defined as “non- contracted.”

Avym can assist in establishing turn key operations with hands on training including relevant forms and implementation of ERISA/PPACA compliant policies and practice.

Each provider or facility is unique. However, most clients do not require a major overhaul.

In most cases there are no upfront fees, however each provider or facility has unique needs.

Many times, denied claims over two years old can still be appealed and collected.

Yes. We can offer services to third-party billing companies.  We also offer training and education to third-party billing companies as well as in-house billing staff.

Yes.  While we are not attorneys, we can advise you on strategies that achieve administrative remedies, assert standing or recover dead or written-off accounts receivables.