In New Jersey and around the country, many employers chose to develop health care plans for their employees that are governed by ERISA (the Employment Retirement Income Security Act of 1974). Because these programs often do not operate exactly like a private health insurance plan, the process to appeal a claim denial is also a little different.
The first step to appeal a denied claim
At times, submitted ERISA claims could be denied because the insurance company believes the procedure was not medically necessary, or it could be a treatment that falls outside of covered offerings. If the claimant disagrees with the insurance company’s decision, they have the right to file an appeal.
To begin the appeal process, the claimant should write a statement that an appeal is being filed and include the documents that form the basis on which the claim should have been paid, including a statement from the treating physician. The claimant’s explanation of benefits form should also be included as well as the policy and group number information.
How to submit the appeal
The insurance plan should have information regarding instructions to submit the appeal. The plan should also provide guidance on the procedure of processing the ERISA appeal and how long it will take to render a decision. The claimant should be diligent in monitoring emails and other methods of communications during this decision time. It will be important to respond promptly to any requests for additional information for the appeal to be processed.
While it may seem intimidating to file an ERISA appeal, chances greatly improve when good, timely documentation is submitted that supports the reason for the appeal. Doing the work necessary in the initial stages of the appeal will help to ensure a favorable outcome.