ERISA

The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans.

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. ACA has developed resources to assist you in harnessing the power of ERISA and making the appeal process as simple as possible. For more information about self insured plans which are governed by ERISA, please visit the website of the Self Insurance Institute of America.

ERISA Overview

ERISA sets standards for: administering private employee health benefit plans (“plans”); disclosing financial and other information to plan participants (“enrollees/beneficiaries”), and processing of health claims. ERISA was enacted to protect the interests of enrollees/beneficiaries and their dependents with private employee benefit plans, and establish one Federal comprehensive law,  thereby reducing the conflict of the employer meeting multiple states’ laws. Examples of the enrollee/beneficiary interests that ERISA attempts to protect include access to financial and other information regarding the plan, a standard of conduct requirement for plan fiduciaries, and consistency in the administration of plans in multiple states. If you have a patient whose healthplan is governed by ERISA, there are steps you can take to ensure that benefits are paid appropriately. 

ERISA Plans

Determining whether an enrollee/beneficiary has an ERISA plan can be difficult. This is due in part to the fact that many of the same networks are contracted by ERISA and non‐ERISA plans. To determine whether an enrollee/beneficiary is covered by and ERISA plan, determine if the plan is provided by a private employer; if so, the plan is an ERISA plan. ERISA regulations only cover plans provided by private employers; therefore, non‐private employer‐provided plans are not covered under ERISA regulations. 

Non‐private plans are provided by: 

  • Government Agencies. 
  • Medicare. 
  • Medicaid. 
  • Public Schools. 
  • Workers’ Compensation. 
  • Military. 
  • Churches. 
  • Any other plans that are not covered by a private employer. 

 

ERISA Appeal Assistance

The resources in this section are member-exclusive content.

ACA has developed a simplified process to walk you through the appeal process, from patient authorization to submission. Learn More >

ERISA Appeal Templates

The resources in this section are member-exclusive content.

If you would like to join ACA and access this and other valuable resources, click here.