ERISA Appeals Assistance

Many doctors of chiropractic do not fully realize the benefits of filing ERISA appeals.  Providers can obtain remedies such as claims payment and when many claims are involved, further gains have been obtained.   The ACA has developed resources to assist you in harnessing the power of ERISA and making the appeal process as simple as possible.  Learn more about ERISA here then follow the simplified steps to begin your ERISA appeal.  For more information about self insured plans which are governed by ERISA, please visit the website of the Self Insurance Institute of America.

 

1.  Appeal Denial-Exhaust all internal and external appeals with the fiduciary (this is the insurer who administers the benefits for the employer).  See www.acatoday.org/appeals for template appeal letters.

Getting Authorization from the Patient
2. Obtain Patient Authorization Form- Download the Patient Authorization Form here
3. Have the patient sign the form. 

Requesting the Summary Plan Description
4. Request a Summary Plan Description (SPD)-Download template letter here.  The patient has the right (as does the provider through the patient’s authorization) to obtain the policy, procedure or protocol upon which the denial was based.
5. Personalize the SPD template letter.
6. Mail the summary plan description request letter with the patient authorization to the fiduciary.

Drafting Your Appeal 
7. Draft Your Appeal-When the SPD is received**, download the ERISA Template Appeal Letter here.
8. Personalize the template appeal letter
9. Make Copies-For the patient, fiduciary and your own records, make a total of three copies of:

     • Signed authorization form
     • Appeal letter
     • Statement of Medical Necessity 
     • Treatment records
     • Insurer’s/network’s denial or restriction of proposed care
     • Plan of care (specific modalities, purpose, frequency/duration, long and short term goals)
     • Patient’s insurance card
     • SPD (or if not received, attach a copy of request for SPD)

Making Copies and Mailing Your Appeal
10. Send a copy of the above documents to:

     • The patient
     • The local EBSA office (http://www.dol.gov/ebsa/aboutebsa/org_chart.html#section13)

11. Place a copy of the above documents in the patient’s chart.
12. Mail original appeal letter along with the above copies and the original authorization form to patient’s employer/fiduciary via certified mail

 

**If SPD is not received, proceed with completing ERISA appeal.  Explain that the fiduciary did not comply with the request and include copies of the request.