Claim denial can be a difficult thing to face, but it’s not necessarily the final decision. It’s important to understand your rights as a beneficiary so that you can take the appropriate actions to get your claim accepted.
ERISA, the Employee Retirement Income Security Act, was passed by Congress in 1974. ERISA laws are there to cover self-funded plans that private employers provide as opposed to non-private plans that are provided by Medicare, Medicaid, government agencies and a host of other institutions. The Summary Plan Description that comes with all ERISA disability policies gives the beneficiary the right to appeal any instance of claim denial.
Why claims are denied and who can appeal them
There are many reasons why it may be hard to determine if an individual’s insurance plan is part of ERISA law. Something that muddies the waters is the fact that you can pay both ERISA and non-ERISA policies through a network like Blue Cross Blue Shield.
One key factor to keep in mind is that policy beneficiaries are the ones who have the right to appeal a denied claim. It is, however, possible to make your doctor an authorized representative. This means that a physician may then act on their patient’s behalf in pursuing an appeal. It’s often helpful to have your primary care physician on your side in the appeals process because they’re better equipped to use the policy information to successfully reverse a denied claim. Here’s what you’ll need to file an appeal:
- Statement of appeal
- Authorization form
- Provider contact information, including NPI number
- Beneficiary information, including plan ID and group number
- Documents in question that led to the appeal
- Patient’s Explanation of Benefits
- Doctor’s dated signature
ERISA claims aren’t always accepted on the first try, even when they should be. However, it is possible to have a denied claim reversed through the appeals process and ensure that you get the coverage you deserve.