The Employee Retirement Income Security Act (ERISA) regulates most private-sector employee benefits. These include health insurance, pension, and other employee benefit plans. ERISA sets standards for how these plans must be managed and administered.
When an ERISA plan provider denies your claim, it can be a frustrating experience. You can visit JPriceMcNamara.com to understand why ERISA claims may be rejected. Understanding the reasons can help you be better prepared to navigate the appeal process.
The following are the reasons why your plan provider denied your claim:
- Lack of Medical Necessity
A lack of medical necessity means your provider must consider the appropriate treatment requested. This can occur when the provider determines that the current medical knowledge does not support the treatment. It can also happen when a less expensive alternative is also effective.
Your provider determines medical necessity and reviews your ERISA claim. They may request more documentation from your physician to support the need for treatment. However, they may deny the claim if they still deem the treatment not medically necessary.
- Pre-Existing Medical Condition
A pre-existing medical condition is an issue that existed before the start of your insurance coverage. Sometimes, health plans may exclude coverage for some pre-existing conditions for a while after you enroll in the program.
You could appeal a claim denial if the insurance denied it due to a pre-existing condition. You can appeal by providing evidence that the situation was unrelated to the pre-existing condition. You may also show that you were unaware of the pre-existing condition when you enrolled in the plan.
However, you should review your plan to understand any exclusions that may apply to your coverage.
- Incorrect Documentation
Incorrect documentation is a situation where you submit a claim that does not meet the requirements of your plan provider. This action can result in a claim being denied, even if the treatment is necessary and covered by the plan.
Incorrect documentation could include missing medical records or incomplete claim forms. Sometimes, your provider may ask for clarification before deciding on the claim. They may only accept your claim if the documentation is provided.
In filing an ERISA claim, you should ensure you provide accurate documents. It would help if you worked with your healthcare providers to ensure accurate claim documentation.
- Failure to Follow Plan Procedures
Health insurance plans have specific requirements to receive coverage for medical services. Some procedures may include obtaining prior authorization before receiving specific treatments. If you follow these procedures, your plan providers may only accept your ERISA claim.
However, you can appeal with your plan provider if it is denied. In the appeal, you can provide information explaining why you failed to follow the procedures.
- Exceeding the Time Limit
Health insurance plans have timeframes for filing claims. Your insurer will only allow your claim if you adhere to the set timeframes.
The timeframes for filing claims can vary depending on your plan and the type of claim. For instance, your cover may need you to file a claim within specified days after receiving medical services.
You should understand the timeframes for filing claims and appeals. Additionally, you should mark important dates to ensure you get all required filings.
Final Thoughts
Having an ERISA claim denied can be stressful, primarily if you rely on it to cover necessary medical treatments. Avoiding the above reasons can help you enjoy the insurance’s benefits.
To help prevent claim denials, you should review your plan and understand your coverage limitations. However, if your insurance denies your claim, you can file an appeal with your plan provider. In the appeal, you can provide extra information to support your claim.
