Urgent Care Claims

[Guest scheim]

Hypothetical:

Self-insured dental plan does not condition receipt of a benefit upon obtaining approval in advance of any procedures. The plan's claims procedure only provides for resolution of post-service claims. I am in extreme pain and need a root canal and call my plan to see if it is covered. The plan tells me "No pre-certification is required. We can't tell you if it will be covered until afterwards." (I know that most times the plan will tell me but remember this is a hypothetical.)

Does the plan violate ERISA Section 503 because it has not established proper claims procedures? The few things I have read have conclusorily stated that an urgent care claim is only such when the plan requires pre-certification (i.e. it is also a pre-service claim) and that seems to be a reasonable conclusion. But to me ERISA 503 is unclear. To make a long story short, it applies to pre-service claims and to post-service claims (2560.503-1(e)). Post service claims are any claim that is not a pre-service claim (2560-503(m)(3)). So what is a claim involving urgent care?

What am I missing?

[Guest Sieve]

I think I undertstand your question, but you will be able to tell from my answer whether or not I really did understand it.

I don't see how a plan that does not require pre-certification of a medical service (i.e., does not condition coverage for the service on pre-certification) fails to provide "reasonable procedures governing the filing of benefit claims, notification of benefit determinations, and approval of adverse benefit determinations" (DOL Reg. Section 2560.503-1(b)) just because the plan fails to voluntarily provide a guarantee in advance that a specific medical service is covered under the plan. There simply is nothing in the statute or the regs that requires certain benefit coverage to be pre-approved, or that requires a claims procedure to provide pre-approval for any specific medical services--it is left entirely to the health care plan to determine when pre-service claims will be required, and then to describe those situations and procedures in the SPD. If filing a pre-service claim is not a condition for receving the medical benefit, then the plan is not required to provide pre-service claims service/approval. The plan must describe all its claims procedures, including any prior approval requirements which are a condition of obtaining a benefit (DOL Reg. Section 2560.503-1(b)(2)), but is not required to provide any specific pre-approval service if it does not so chose.

A pre-service claim is one where receipt of a benefit under the plan specifically depends on approval of the benefit before the medical care is provided. An urgent care claim is one where pre-authorization must be determined more quickly than normal because of the patient's medical condition. Although the regs do not differentiate between a pre-service and post-service urgent care claim, it makes no logical sense that an urgent care post-service claim should necessarily be resolved on a quicker timetable than a non-urgent care post-service claim.

So, if your tooth hurts badly, but receving a root-canal does not require pre-approval under the plan, then you may certainly have an urgent-care situation, but you do not yet have a "claim involving urgent care" at that time if the plan does not entertain pre-service root canal coverage determinations as a pre-condition to covering that service under the plan.

I hope that at least comes close to answering your question.