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Appeal/Document Request

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We have a situation where an entity is requesting documents/appealing a denial of a claim. The entity attached a form whereby the participant designed and assigned his/her rights to the hospital. However, the hospital was not the entity making the request, so we told the entity sorry, you aren't the authorized rep, the hospital is, then the entity sent us the fee arrangement between it and the hospital for collections, etc. I'm still inclined to say sorry - this is not sufficient to demonstrate the participant named your entity as the authorized rep... in fact, participant named hospital, not you. Thoughts??

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Speak to ERISA counsel on this. These types of document requests and appeals are increasing in number. Perhaps sending the requested documents to the employee him or herself is appropriate. You also need to coordinate with the claims administrator to the extent a valid appeal is included.

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Among the many questions you might ask for your ERISA lawyer's advice:

Does the plan permit or restrict an assignment of a participant's claim?

If the plan permits any assignment, does it restrict permissible assignees to healthcare providers?

Even if the plan permits an assignment of a claim, does the plan's claims procedure permit (or preclude) an assignee from acting as a claimant's representative?

Peter Gulia PC

Fiduciary Guidance Counsel

Philadelphia, Pennsylvania



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