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Conflict between 1) plan doc and 2) K between facility and payer


Guest missy
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If a hospital submits an appeal to a payer/insurance company(and it is timely pursuant to the contract between the two parties) and the payer/insurance company responds the appeal is untimely based on the plan participant's document, which document prevails? Assume this issue falls under ERISA. Also, the hospital has an agreement with the payer/insurance company for discounted rates and no agreement with the employer for discounted rates.

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Need a lot more detail...

The issue will ultimately be whether the facility's claim is subject to ERISA or subject to state law.

It depends on the relationships. Is the payer the plan or the employer or someone else? Is the "facility" a clinic or something that has contracted with the employer to be a service provider to the plan? Etc., etc.

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It looks like there are more facts now. But I guess that what I'm saying is that we'd need to know which arrangement governed the specific claim in order to know whether it was timely or not. I'm guessing that there are several arrangements between several parties -- each of which may or may not apply to the specific claim.

There is a participant, an employer, a plan, a service provider (the "hospital"?), a third party insurance company, etc. There may be arrangements between the participant and the hospital, between the insurance company and the employer and/or plan, between the insurance company and the hospital, and between the hospital and the employer and/or plan. The insurance company could be acting as an insurer or providing administrative services only. And various other considerations....

The hospital's arrangement with the insurance company does not necessarily extend to every claim in which they are both involved. That contractual arrangement may be irrelevant here. (That sounds like what the insurance company is saying?)

If the insurance company is not obligated to pay this claim under their contract, then the question is who is obligated to pay? And what conditions (such as timely submissions of claims) must the hospital meet in order to get paid?

The hospital could have arranged with the employer and/or plan to submit claims directly to the insurance company on behalf of the employees. Or the hospital may be doing so voluntarily.

So maybe the only relevant contractual relationship is that between the participant and the hospital. The hospital will bill the participant for the amount not claimed. The participant will submit the claim to the plan again. If the plan doesn't pay the participant (because it wasn't submitted timely), then the hospital may never collect. (Not because it's not entitled to, but because the participant doesn't have any resources...)

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