TPA states we must subpoena records in disputed claim?

[Guest Diana Prewitt]

We have a self-funded medical and dental plan and I am new to the organization that is considered the "administrator." Our TPA states we must legally request via subpoena medical records to be considered in a claim that is being contested. The employee (not our employee, but another covered company) is presenting information of which we had no prior knowledge. I am very concerned that we (my Executive Director and I) are being asked to make a final decision on a claim where we don't seem to have full knowledge. Is this correct that we must subpoena to be certain of what our TPA has indeed received on this case? Also, is it extremely critical that the final decision be made prior to the surgery which is scheduled for December 28?

[jeanine]

It's not clear to me whose medical records you want and why. From your message it appears you want to look at someone's medical records to make a decision for treatment of another individual, who I think is your employee. Is this correct? If this is the case I don't see how you will ever get those records, even with a subpoena.

[GBurns]

What do you mean "is considered the "administrator""? Who adjudicates your claims? If not the TPA, then why have a TPA?Who are you to serve the subpoena on?? How do you do this without filing a lawsuit first? What gives you any authority to look at anyone's records?? You have a lot of unanswered questions about your method of operation.