If you participate in a health plan or a plan that provides disability benefits, you will want to know how to file a claim for benefits. The steps outlined below describe some of the duties of his plan and briefly explains the procedures and deadlines for filing a claim for health benefits or disability.
Health Care and ERISA Law
Before claiming, however, consider ERISA a law that protects your health and disability benefits and sets standards for those manage their plan. Among other things, the law and rules promulgated by the Department of Labor include requirements for processing benefit claims, the deadline to make a decision when you make a claim and your rights when a claim is denied.
Affordable Health Care Act ACA Changes
The Affordable Health Care Act ACA adds important protections associated with occupational group health plans to improve medical coverage for you and your family.There will be additional protections available in 2014. For more information, visit the website of the ACA Administration Employee Benefits Security in www.dol.gov/ebsa/healthreform .
You should know that ERISA does not cover some employee benefit plans (such as those sponsored by government entities and most churches). However, if you’re one of the millions of participants and beneficiaries who depend on the health benefits or disability of a plan for private sector employees take a few minutes to read on and learn more.
Review Summary Plan Description
A key document related to your plan’s summary plan description (SPD). The SPD provides a detailed overview of the plan – how it works, what benefits and how to file a claim for benefits. It also describes your rights and responsibilities under ERISA and plan. For some plans of a single employer collectively bargained, you should also review the procedures for filing claims, complaints and appeals of the collective bargaining agreement, as they may not apply to claims for health benefits and disability.
Applying for Health or Disability Benefits
Before applying for health or disability benefits, review the SPD to ensure that it meets the requirements of the plan and understand the procedures for the claim. Sometimes claims procedures are in a separate booklet that came with your SPD. If you do not have a copy of your plan’s SPD or claims procedures, request in writing to your plan administrator. The employer obligated to supply a copy.
How to complain about Health Benefits or Disability Benefits
An important first step is to check your SPD to make sure it meets the requirements of your plan for benefits. Your plan may say, for example, that passes a waiting period before you can register to receive benefits, or a dependent is not covered after a certain age. Also note what your plan requires to file a claim. The SPD or claims procedure booklet should include information on where to file, how to present and who to contact if you have questions about your plan, such as a necessary process for granting approval for health benefits. Plans may not charge any fee or cost for filing claims and appeals.
If, for some reason, that information is not in the SPD or claims procedure booklet, write your plan administrator, the human resources department of your employer (or office that normally handles claims) or employer notifying you have a claim. Keep a copy of the letter for your records. You’ll also want to send the letter by certified mail, return receipt requested, so you have a record that the letter was received and by whom.
If the person filing the complaint is not you, but an authorized representative, that person should refer to the SPD and follow the procedure for claims of his plan.Your plan may require you to fill out a form to designate the representative. If it is an emergency, the physician can automatically become their authorized without having to fill out a form representative. When an ERISA claim is made, be sure to keep a copy for your records.
Types of ERISA Claims
All claims for health benefits and disability should be decided within a specified time limit, depending on the type of claim filed.
The group health claims are divided into three types: Claims urgent care, pre-service and post-service , and the type of claim determines how fast a decision must be made. The plan must decide what type of claim is, except when a physician determines that urgent attention is needed.
Urgent care claims are a type of pre-service special that requires a faster decision claim that their health would be threatened if the plan took the normal allowed to decide on a pre-service claim time. If a doctor who knows your medical condition tells the plan that is urgent pre-service claim, the plan must treat it as urgent care.
The pre-service claims are requests for approval to the plan requires you to obtain prior to seeking such care as an approval or a decision on whether a treatment or procedure is medically necessary.
The post-service claims are all other claims for benefits under your group health plan, including those after having given physicians, such as requests for reimbursement or payment of costs of services provided services. Most claims for group health benefits are post-service.
Disability claims are claims for benefits in the plan must make a determination of incapacity to decide on them.
Awaiting a decision on your ERISA claim
As indicated above, ERISA sets specific time periods for plans to evaluate your complaint and notify a decision. Time limits are counted in calendar days, so weekends and holidays included. These limits do not apply when benefits are payable or provided. If you qualify for benefits, check your SPD for how and when to pay. Plans are required to pay or provide benefits within a reasonable time after the approval of the claim.
Urgent care claims and ERISA
Urgent care claims must be decided as soon as possible, taking into account the medical needs of the patient, but no later than 72 hours after the plan receives the claim. The plan must tell within 24 hours if more information is required; you will have no less than 48 hours to respond. Then, the plan must decide the claim within 48 hours at which supplied the missing information or the timeframe for this finished. The plan can not extend the time for making the initial decision without their consent. The plan should notice that your claim has been approved or denied by the end of the time allotted for the decision. You can notify verbally on the benefit determination always to be issued a written decision within three days notice to the verbal notification.
The pre-service claims and ERISA
The pre-service claims must be decided on a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after the plan has received the complaint. The plan may extend the period of time up to 15 days if, for reasons that are not in their power, the decision can not be taken within the first 15 days. The plan administrator must notify you before the end of the first 15 days, explaining the reason for the delay, requesting any additional information and informing when the plan expects to make a decision. If more information is requested, you have at least 45 days to supply. The plan then must decide the claim not later than 15 days after you provide any additional information or after the period of time allowed for this end, whichever comes first. If the plan for more time, you need their consent. The plan should notice that your claim has been approved or denied by the end of the time allotted for the decision.
The post-service claims and ERISA
The post-service claims must be decided within a reasonable period of time, but no later than 30 days after the plan has received the complaint. If, for reasons that are not in their possession, the plan needs more time to review your application, this may extend the period of time up to 15 additional days.However, the plan administrator must notify you before the end of the first 30 days, explaining the reason for the delay, requesting any additional information necessary and informing when they are expected to have a decision. If more information is requested, you have at least 45 days to supply. The complaint must be decided no later than 15 days after you provide any additional information or after the period of time allowed for this end, whichever comes first. The plan needs your consent for more time after its first extension. The plan should notice that your claim has been denied in whole or in part (with lower pay 100 percent of the claim) before the end of the time allotted for the decision.
Disability claims and ERISA
Disability claims must be decided within a reasonable period of time, but no later than 45 days after the plan has received the complaint. If, for reasons beyond its control, the plan needs more time to review your application, this may extend the period of time up to 30 days. The plan must give before the end of the first 45 days you need more time explaining why, any unresolved issues and any additional information needed, and when you expect to issue a final decision.If more information is requested during any extension of time, you have at least 45 days to supply. The complaint must be decided no later than 30 days after you provide any additional information or after the time allowed for it ends, whichever comes first. The plan administrator may extend the period for up to another 30 days if notified before the end of the first extension. For any further extension, the plan requires consent. The plan must notify you if your claim has been denied before the end of the time allotted for the decision.
If your claim is denied, the plan administrator must notify you in writing or electronically, with a detailed explanation of why the denial and a description of the appeals process. Additionally, the plan must include rules, guidelines, protocols or exclusions (such as medical necessity or experimental treatment) used in the decision or give instructions on how to request a copy of the plan. The notice may also include a special request that you provide additional information to plan if you want to appeal your denial.
How to appeal a denied ERISA claim
Claims are denied for various reasons. Perhaps the services you received are not covered by your plan. Or perhaps the plan simply need more information about your claim. Whatever the reason, you have at least 180 days to file an appeal (check your SPD or claims procedure to see if your plan provides a longer term.)
Use the information in your claim denial notice to prepare his appeal. You should also note that the plan must provide claimants, on request and free of charge, copies of documents, records and other information relevant to the claim for benefits. The plan should also identify, at its request, any medical or vocational experts whose advice was obtained by the same plan. Be sure to include in your appeal all the information related to your claim, especially any additional information or evidence you want the plan to consider and take it to the person specified in the notice of refusal before the end of the period of 180 days.
How to review an appeal
On appeal, his claim must be reviewed by someone new to look all information submitted and consult with qualified if a medical judgment is involved medical professionals. This reviewer can not be a subordinate of the person who made the initial decision and should not consider this decision.
The plans have specific periods to review your appeal, depending on the type of claim.
Claims for urgent attention should be reviewed as soon as possible, taking into account the medical needs of the patient, but no later than 72 hours after the plan receives your request to review a denied claim.
The pre-service claims are reviewed within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days after the plan receives your request to review a denied claim.
The post-service claims are reviewed within a reasonable time, but not later than 60 days after the plan receives your request to review a denied claim.
If a group health plan needs more time, it must have consent. If you disagree with extended time, the plan must complete the review within the time allowed.
Disability claims should be reviewed within a reasonable period of time, but no later than 45 days after the plan receives your request to review a denied claim. If the plan determines that special circumstances exist and an extension, it can take up to 45 additional days to decide on the appeal is needed. However, before taking the extension, the plan must notify you in writing during the first 45 days explaining the special circumstances and the date on which it expects to make a decision.
There are two exceptions to these limits. In general, a single employer plans whose benefits have been negotiated through collective bargaining, can use a collectively negotiated grievance procedure for claims appeal process if it has provisions on presentation, determination and review of claims for benefits. The plans of multiple employers collectively negotiated get special deadlines to allow appeals to program reviews post-service claims and disability during regular quarterly meetings of their boards. If you are a participant in one of these plans and procedures have questions about your plan, you can check your SPD or contact Security Administration Employee Benefits Department of Labor (EBSA)
The plans may require you to go through two levels of review of a health or disability claim denied to complete the claims process thereof. If two revision levels are required, the maximum time for each review is generally half of that allowed for a review. For example, in the case of a group health plan with a level of appeal, as noted above, the review of a pre-service claim must be made within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days after the plan receives your appeal. If the plan requires two appeals, each review must be completed within 15 days for pre-service claims. If your claim is still denied appealed after the first review, the plan must allow a reasonable period of time (but not all 180 days) to file a second review.
Once a final decision on your claim is made, the plan must send you a written explanation of the decision. The notice must be in plain language that can be understood by plan participants. You must include all the specific reasons for the denial of his claim on appeal, forward to the provisions of the plan on which the decision was based, say if the plan has some level of voluntary appeal, explain your right to receive relevant documents your claim for benefits for free and describe your rights to seek judicial review of the decision of the plan.
If your appeal is denied
If the final decision of the plan denies your claim, you can seek legal advice regarding their rights to take legal action to challenge the denial. Normally, you should end your claims process plan before filing a lawsuit to challenge the denial of a claim for benefits. However, if you believe that your plan has not established or followed a claims procedure consistent with Department rules described in this booklet, you can seek legal advice regarding their right to ask a court to review your claim for benefits without waiting for the decision of the plan. You can also contact the nearest EBSA office to inquire about your rights if you think the plan has not followed any of the requirements of ERISA in handling your claim for benefits.