In Washington DC, people who have health benefits are accorded certain protections through ERISA (the Employee Retirement Income Security Act of 1974). With these protections, people who have health care coverage through a private sector plan can get their plan information and make sure that the plan managers adhere to certain standards. A key part of ERISA is the right to appeal when a claim is denied. Often, people who are unfamiliar with ERISA do not understand the basics. Knowing about the three types of claims that are filed under ERISA is imperative, as is knowing what steps are available if there is a denial.
Urgent care, pre-service and post-service
The three claims that are made under ERISA are for urgent care, pre-service and post-service. The deadlines for a decision on the claim vary. As the name “urgent care” implies, there will be a quicker decision and the person will wait a maximum of 72 hours. Pre-service has a 15-day maximum. Post-service has a 30-day maximum. Under ERISA with urgent care, the plan is required to inform the person if more information is necessary within 24 hours. There will be 48 hours to respond. If there is more information needed, the decision on the claim will be made within another 48 hours. The plan must inform the person as to whether the claim is granted or denied.
The medical situation will dictate how soon a pre-service claim is decided upon. There is the 15-day maximum, but it can extend it for another 15 days if the decision cannot be made in that time-frame. The person must be told why there is a delay; asked for more information as needed; and advised as to when the decision will be made. When more information is needed, the person has 45 days to provide it. With post-service claims, it is a 30-day maximum with a 15-day extension as needed. The same requirements apply as for pre-service claims.
ERISA claims can be complicated and professional guidance can help
These issues might not seem important, but if there is a delay or a denial of the claim, it can cause myriad problems. ERISA is in place to protect people and give them the option to appeal a denied claim. The plan must give detailed information as to its decision and explain why there was a denial. Having professional assistance in evaluating the plan and appealing the denial to be reimbursed for payouts or to be covered for expenses can be vital. Consulting with those experienced in the complex terrain of ERISA and appeals is a wise decision.