karen1027

Are there any regulations for a time limit for self-finded health insurance plan to process their claims and issue a check? Finally got the insurance provider to implement the QMCSO, now it's taking forever to get a reimbursement check. Been advised that they issue check to policy holder first and then have to void that check and reissue to alternate recipient. There are some claims that finalized in late June/early July and I've yet to receive a check payment..

Amazingly, after over one year, my ex's employer and health insurance provider, have agreed to implement the QMCSO! I was repeatedly denied by both the employer (who kept pushing it off to the insurance carrier - Isn't it their responsibility to ensure the Order is followed?) and the insurance carrier (who claimed they COULDN'T follow the Order and did NOT have to follow the Order). I provided the employer and the insurance company with a listing of claims that I did not receive reimbursement; they, in turn, have had the insurer send me a listing of all claims paid to my ex in which the checks were cashed by the ex, and want me to indicate what claims I was not reimbursed by anyone. Is there a reason they are doing this? I provided them a list. Insurer has indicated they will go after the ex for a refund of those items I identify. Insurance company now indicates their legal department agrees they have to follow the QMCS - last year I was told their legal department indicated they did not have to comply and that I should take my ex to small claims court (among other "recommendations..) Yesterday I received two checks - the claims were not on the list I provided and the reimbursement is now a higher amount! (I have no idea how they balance their books.) Why are they asking me to review a listing of reimbursements?

What rules do self-insured plans have to follow? Must they comply with laws in the state the subscriber resides? Just received notice that an expensive medication will no longer be covered. Anything I can do? FDA issued warning last Fall that generic form is not as effective and is not equilivant to brand.

Explanation of Benefits are sent to the children's address, not the father's. They are in their early 20's. I have asked several times for the Plan Admisitrator to send me the firm's QMCSO procedure - the request is ignored.

Yes, mail was opened by their father (seems he could have just forwarded each letter to each kid. They are not minors - both are over 18 - one is emanciapted - finished college - other is still in college (although there are issues regarding child support for that child). Health insurance company has address for the children - QMCSO gives their address.

Parents are divorced. Children live with mother. Health insurer mails out a letter to two children (each received a letter, addressed to them at their father's residence). Letter contains information regarding a prescription medication they take, gives name of medication. Letter is dated"may 2013". Just received letter from father today. Aren't the name of medications covered under HIPPA rules and regulations?

Thank you - that's what I thought. I've asked the Plan Adminstrator for additional documents. ii.e. their QMCSO procedures - they just ignore the request.... The health insurance carrier claims they can't (nor do they have to) reimburse me; however, for a very brief period last year (about two months) I received checks from the health insuance carrier after spending an inordinate amount of time trying to get directly reimbursed. The past 8 months I've received nothing. The contract with the insurer has been in effect since 1/1/11. Been advised to get an employee benefits attorney - is that correct?

Does a Plan Administrator ever make reimbursement payments to alternate recipients? Plan administrator keeps sending me back to the health insurance carrier who claims the insurance carrier can not make reimbursement payments to the alternate recipient.

Who is responsible for ensuring compliance with a QMCSO? The employer? The health insurance company? Employer keeps sending me back to the insurance company.... Plan is self-insured. According to QMCSO, reimbursement payments are to be made payable to alternate recipient.; however, checks go to non-custodial parent. DOL states I must file my own lawsuit.

Shouldn't EOB's indicate who received payment from the insurance company?

The patients did NOT sign any authorization. I advised the plan administrator that there were several claims that I had not received reimbursement. There is a QMCSO in effect, but is not followed. Plan adminstrator requested dates of service, patient's and provider's name. In response, I received copies of a couple of "Claim Details" and several EOB's, most of which were not for the dates of service I indicated. Also the EOB's do not indicate to whom paymnet was made..

The health insurance company has released copies of EOB's to the employer. Is this a violation of HIPAA laws?

The insurance company now states that they will issue reimbursement checks to the children (i.e not me the custodial parent who paid for these services and is indicated on the QMCSO as the alternate recipient custodial parent). The Order states: Any payment of medical benefits made pursuant to this Order is reombursement of expenses paid by an Alternate Recipient or an Alternate Recipient's custodial parent, as applicable, shall be made to the Alternate Recipient or the Alternate Recipient's custodial parent paying such expenses. Of course, I, nor my kids, haven't received any checks but shouldn't the checks be issued to me?

Just been advised by insurance company that company has removed QMCSO..... I am no longer receiving reimbursement checks. Round and round we go

Has this gone into effect? If so, why are some insurance companies asking if a child is a full-time student?

No one wants to litigate this - insurance company os blatantly ignoring the Order.

One additional question, insurer now claims (but hasn't done) that any child over the age of 21 will receive the reimbursement check rather than the custodial parent. Is that accurate? NO checks have been issued to them..

I'm getting no where with the insurance company. It's hit or miss that I receive reimbursement checks. What specialty lawyer would I contact to assist me with getting the insurance company to comply with a QMCSO?

There is a QMCSO in place for my three children. After almost two years, the order has finally been put in place with the latest health insurance carrier. I have received a couple of reimbursement checks but have now been advised by the non-custodial parent that the checks will no longer be made payable to me, the custodial parent, but to each of the three children since the children are now over the age of 21. They have NOT been emancipated. The QMCSO states reimbursements are to be made payable to me and notices shall be sent to me. Of course, I am the parent who has paid for these medical services. Can the insurance company now make the checks payable to the children?

My children are covered under a self-insured health insurance plan under their father's firm. I have finally started to get checks from the insurance company; however, the checks are "voucher checks". I am not receiving explanation of benefits for these checks. Shouldn't I receive an explanation of how these claims were paid as well as an EOB when there is no payment or the payment goes to someone else? I'm also confused as to why I get these voucher checks rather than the "normal" check one usually gets from the health insurance company.

You need a Court Order to get reimbursement.

Are you looking for reimbursement directly from the insurance company?

Karen, There are usually three parties involved; employer, plan admin, and carrier: - The employer contracts with the carrier for insurance. - The employer can then act as its own plan admin or hire someone else to be the plan admin to carry out the business of the contract as a whole. The carrier cannot be the plan admin. - The plan admin can then delegate to the carrier just the part of the contract for claims processing but still remains legally responsible for claims processing. The 29 USC 1169 law puts responsibility on the employer to: - determine if the order is a medical child support order (MCSO), - determine if the MCSO is qualified (QMCSO), - notify all involved; parents, plan admin if QMCSO, parents only if not QMCSO, - mandatorily withhold premiums from the employee's paycheck and provide to the plan admin, - keep the child enrolled during the term of the order despite anyone's request to disenroll, and - notify the court if the employee loses insurance; i.e. tries to disenroll while still eligible, is terminated, or dies. The plan admin is responsible for: - sending plan documents to the child via the custodial parent; i.e. benefits summary, claims forms, id cards, etc, - notifying the carrier and - directing the carrier to allow the custodial parent to receive information (EOBs, letters, etc.), assign benefits to providers, file claims and receive all reimbursements owed by the carrier (not reimbursements owed by the ordered parent). As a condition to receive US medicare/medicaid and DSS funds, states are required to have state laws on the books identical to 29 USC 1169. Check your state laws. Non-self funded plans must comply with state and US laws. Self-funded plans only comply with US laws; i.e. state departments of insurance have no jurisdication to enforce any laws on self-funded plans. If the state laws differ from the US laws, the US laws take priority on the QMCSO issue. Like you, I am a custodial mother with a QMCSO and difficult father/employer/plan admin/multiple carriers and have dealt with this same problem extensively since 2007. You'll find attorneys, local courts, employers and many carriers are unfamiliar with QMCSO laws although the laws are more than 15 years old. I was successful in achieving the QMCSO with the assistance of US DOL against the employer/plan admin, US HHS against the carrier, and state DSS and state appellate court against the father and employer. Let me know if you would like to discuss via phone. What did US DOL tell you? It is a self-funded fund. DOL says the insurance company (united Health Care) does not have to comply with the QMCSO. UHC, through their legal department, has indicated to me that they do not provide "that option", i.e. issuing checks to alternate recipients, custodial parents.

Thank you LIsa. I have submitted the Court Order which is a Qualified Medical Child Support Order, issued by a judge many years ago, to both the ex's employer and the health insurance company. (It's been submitted to several health insurance companies in the past several years and there has not been a problem in compliance with sending, and making payable to me, the reimbursement checks from the health insurance carrier) The health insurance carrier refuses to send me the reimbursement checks; instead they are going to my ex-spouse who, in turn, is withholding part of the reimbursement check; i.e. he applies the check to other expenses he owes me not for the actaul exoense the check is for. I have paid for the services for the children. I should get the full reimbursement from the insurance comapny (plus his percentage of the remaining out of pocket from him) His employer (he's a partner is a large, multinational law firm) has not complied with the order in any regard other than to tell me it's a qualified order. They haven't followed any other procedures that they are suppose to. Even ID cards for the children aren't mailed directly to them. I am not familiar with DSS. Child Support payments are paid to me directly, there is no state agency involved. (which is/was a mistake!). I hope this makes it clearer. I am disabled and unable to work If firm is self-insured, is the firm in non-compliance?

Thank you LIsa. I have submitted the Court Order which is a Qualified Medical Child Support Order, issued by a judge many years ago, to both the ex's employer and the health insurance company. (It's been submitted to several health insurance companies in the past several years and there has not been a problem in compliance with sending, and making payable to me, the reimbursement checks from the health insurance carrier) The health insurance carrier refuses to send me the reimbursement checks; instead they are going to my ex-spouse who, in turn, is withholding part of the reimbursement check; i.e. he applies the check to other expenses he owes me not for the actaul exoense the check is for. I have paid for the services for the children. I should get the full reimbursement from the insurance comapny (plus his percentage of the remaining out of pocket from him) His employer (he's a partner is a large, multinational law firm) has not complied with the order in any regard other than to tell me it's a qualified order. They haven't followed any other procedures that they are suppose to. Even ID cards for the children aren't mailed directly to them. I am not familiar with DSS. Child Support payments are paid to me directly, there is no state agency involved. (which is/was a mistake!). I hope this makes it clearer. I am disabled and unable to work