know very little about their dental or medical
insurance plans. An informed patient can be of
invaluable assistance to your practice when problems
arise with claims. ERISA (the Employee Retirement
Income Security Act) is a federal law that protects
individuals employed in the private sector by
setting standards for administering those insurance
plans. Those standards require plans to give you
important information about the plan and to have
an equitable process for handling the claims.
The following are the steps that patients should
take when appealing a claim:
1. Obtain a copy of the Summary Plan Description
The patient is entitled to a summary plan description.
It gives a detailed summary of the plan –
how it works, what the benefits are, and how to
file a claim. The SPD is a document that the plan
administrator must provide the patient when the
patient joins the plan.
2. File a claim
3. Time period for a decision on the claim
The plan’s claims procedure provides the
time within which the plan must provide the patient
with a decision.
4. If the claim denies:
If the patient chooses to appeal, the plan administrator
must tell the patient how to appeal the denied
claim for a full and fair review. The plan will
specify the number of days that the patient has
to file an appeal and it may provide for extensions
of that time period. In addition, the plan should
also specify the time period for making a decision
on the appeal.
5. If the appeal is denied:
The patient must be given a reason that shows
the plan rules upon which the denial was made.
Should the patient still disagree with the final
decision or if the plan fails to make a timely
decision, he or she has the right under the ERISA
law to file suit in court to obtain benefits.
For further information on patient’s rights
under ERISA, contact the Pension and Welfare Benefits
Administration’s toll free publications
hotline at 1-800-998-7542.
You may use my form
or your practice can develop its own insurance
information form with the information given here
that can be given to insured patients. Remember
– insurance plans are contracts between
the patient and the insurance company. You can
help your patients and your practice by informing
them about their rights.
The form for notifying patients about their rights
can be seen here.
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