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When does this go into effect?
The rules are effective
for groups with plan years effective beginning July 1, 2002.
However, all groups must comply by January 1, 2003.
Who do the rules apply to?
All group health and
disability plans established or maintained under ERISA (insured
and self-funded).
Are some plans not affected?
Yes, some plans do not
have to comply with these rules. The most common types of plans
that do not have to comply are Governmental Plans and Church
Plans.
Who do the rules affect?
The rule will affect:
- Subscribers and members of
employer benefit plans
- Employers who sponsor employee
benefit plans
- Plan fiduciaries
- TPA's
Who is the "claimant"
in regards to the claim rules?
The claimant is always
the member. A provider of service is not a claimant under these
rules.
Can a member authorize someone
else to represent them?
Yes, a member may appoint
an authorized representative to act on their behalf in pursuing
a benefit claim or appeal. Your plan may require you designate
your authorized representative in writing. An "assignment
of benefits" does not designate a provider of
service as your representative.
What is a Pre-service claim?
A pre-service claim is
any claim, that in order to receive benefits in whole or in
part, must be approved by OSFHP in advance of obtaining the
medical care.
What is a Post-service claim?
A post-service claim is
any claim for benefits where the service has already been
rendered prior to OSFHP being notified.
What is the difference between a
pre-authorization and a referral?
Services that require
pre-authorization must be approved by the Healthplan prior to a
service being rendered in order to be eligible for benefits.
Services that require a referral
must be approved by the PCP prior to a service being rendered in
order to be eligible for benefits.
For specific information on which
services require a pre-authorization or a referral, please see
your policy and procedure manual.
If a claim is denied for no
authorization or referral by OSFHP, can the member be balanced
billed?
After 7/1/02, if a
provider renders services to an OSFHP member without verifying a
required pre-authorization or referral has been obtained, they
will not be able to bill a member for any charges not paid by
the Plan.
Are other payors affected by the
DOL ERISA claims rules?
All payors are affected
by the new law, but that doesn't mean that all carriers may
comply in the same manner. If you deal with multiple carriers,
you should contact those carriers or consult their policy and
procedures manual.
Can I appeal a denied claim on my
patient's behalf?
Under plans governed by
the DOL rules, adverse benefit determinations are to be appealed
by the claimant, unless they appoint an authorized
representative. The provider may be appointed the authorized
representative by the claimant, however, this would require that
all communication be sent to the provider and the provider would
be responsible for keeping the patient informed of the appeal
status/disposition. If you wish to be appointed an authorized
representative, the patient should contact OSHP's member
services department to obtain the proper forms.
Where can I find the full text of
the regulation?
To find the full text of
the regulation you can go to the DOL website at click
here,
then select Final Rules. From the list, select Employee
Retirement Income Security Act of 1974; Rules and Regulations
for Administration and Enforcement; Claims Procedure; Final Rule
[11/21/2000].
You can also find additional
information at the same website address, after you select Final
Rules select Employee Retirement Income Security Act of 1974;
Rules and Regulations for Administration and Enforcement; Claims
Procedure; Final Rule [07/09/2001].
A FAQ document can be found here.
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