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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
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).
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.
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.”
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.