 |
 ACA's template letters can help you with filing an appeal. Click here for more info. |
|
|
|
ERISA, which is administered through the U.S. Department of Labor (DOL), was passed in 1974 and was intended to encourage large multi-state employers to provide pension, health care and other compensation to their employees by shielding them from various state laws governing pension and insurance laws and instead, requiring compliance with one set of federal laws. Here you will find what you need to know about ERISA and how it can affect your practice as a doctor of chiropractic. |
|
 |
|
|
 ACA Educational Materials on the 2003 Rulings and Impact on Chiropractic
The ERISA law made it difficult for individuals to get relief for denied claims or botched treatment. About 80 percent of workers not covered by a government-based health plan receive their health care through an ERISA-protected plan. In response, the Department of Labor (DOL) issued new claim appeal procedures effective for all health benefit plans subject to ERISA regulations. It includes a specific time frame for filing an appeal, spells out the rights of the plan participants and responsibilities of the plans, and requires the plan to indicate why and on what basis a claim is denied. ACA's ERISA educational materials discuss the 2003 rulings and their impact on chiropractic in greater detail.
|
| ACA Live TeleSeminar CD ROM on ERISA: What You Need to Know |
 |
|
|
This comprehensive program, presented by ACA's legal counsel and insurance manager in August, 2004, covers everything you need to know about the ERISA claim and appeal process. Topics include: regulatory changes, provider claims submission requirements, plan administrator requirements, appeal timelines, the denied claims appeal process, enrollee/beneficiary rights, authorization forms and other resources. Order your copy today through ACA's virtual store.
|
| ERISA Claims Practice Tips: What if a claim is denied? |
|
|
|
If a claim is denied for reasons of medical necessity, doctors and patients have the right to know the identity of the reviewer (who should have appropriate training and experience in the specific health care field involved) and his or her reasons for the denial. Once this information is known, doctors should submit any additional evidence supporting their treatment decisions to the health plan to be included in the official administrative record. Attention to such details of the appeals process is essential; otherwise, evidence may not be admissible further down the line.
|
| Down-coding, Bundling and Partial Claim Payments under ERISA |
|
|
|
According to the U.S. Department of Labor frequently asked questions an "adverse benefit determination," which triggers the right of an ERISA plan claim appeal, occurs when the claimant receives "less than full reimbursement of the submitted expense." Down-coding, bundling and partial payment are all potential forms of "less than full reimbursement."
|
|
|
|
