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need help with hysteroscopy removal iud insurance denied

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Michele:

--- Quote from: kristin on August 01, 2016, 11:06:32 PM ---Take it to the next level of appeal. And the next, if necessary. Don't give up.

--- End quote ---

Ditto.   I wouldn't accept that answer.  I would also ask the patient to inquire with their employer as well, since ultimately she will be responsible if they don't pay.

PMRNC:

--- Quote --- I have already sent all documentation with a letter explaining the medical necessity for the use of the iud on this patient, and the insurance co. still denied appeal saying pt needs to address medical necessity with her employer.
--- End quote ---

If this is an employer group health plan you want to do an appeal using ERISA. Have the patient sign a valid Authorization for representation with you and have them contact the employer. It sounds like self-administered plan which gives the employer a bit more lead-way in getting things paid so I would get the patient involved. Also since this is ERISA you want to have the patient give you a copy of their SPB.. I HAVE seen plans that exclude contraceptive DEVICES.. PERIOD.

goldeneyes711@msn.com:

--- Quote from: PMRNC on August 02, 2016, 12:08:48 PM ---
--- Quote --- I have already sent all documentation with a letter explaining the medical necessity for the use of the iud on this patient, and the insurance co. still denied appeal saying pt needs to address medical necessity with her employer.
--- End quote ---

If this is an employer group health plan you want to do an appeal using ERISA. Have the patient sign a valid Authorization for representation with you and have them contact the employer. It sounds like self-administered plan which gives the employer a bit more lead-way in getting things paid so I would get the patient involved. Also since this is ERISA you want to have the patient give you a copy of their SPB.. I HAVE seen plans that exclude contraceptive DEVICES.. PERIOD.

--- End quote ---

Many thanks PMRNC, for your great response. Yes, apparently the patient has a self-administered plan. Therefore, I have asked the patient already to get in touch with the employer and resolve the medical  necessity issue with them as advised by the insurance co. SPB-summary of policy benefits?? In all the years I have been doing medical billing this will be the first time doing an ERISA appeal. What have your experience been with them if any?

Again many thanks.

PMRNC:

--- Quote --- In all the years I have been doing medical billing this will be the first time doing an ERISA appeal. What have your experience been with them if any?

--- End quote ---

Bet you it's not you just don't realize it. More than 85% of the claims you touch are ERISA (group sponsored plans) ERISA is federal therefore they are overseen by the DOL. Any group health plan with the exception of state/govt or church are ERISA which is why I say you have touched many more ERISA claims than you have NON ERISA claims. :)

The SPB is the Summary Plan Benefit. If you choose to help the patient it's a good idea to get a copy of their SPB. At the same time they should sign what is called an ERISA Authorized Representative Form. This is a special form that the patient signs to allow you to represent them in the appeal. With ERISA the claims are not the providers claim, they are the patient's claim. Same thing if a carrier comes back and wants to recoup money on claims they paid to the provider, they cannot because they should go to the patient for the money back, NOT the doctor. Imagine how much money doctors have given back because they or their billing staff didn't understand ERISA? A LOT Of money!!!

Don Self has a great book on ERISA and appeals.. It should be on every billers must have list. www.donself.com

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