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Urgent Care Claims


Guest scheim

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Guest scheim

I posted this in the "Litigation and Claims" forum and did not get any responses. Since it is health plan-related question I thought I'd try here:

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?

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Actually, most plans will answer the same way, (We can't tell you if it will be covered until afterwards."), or at least they should. They are being cautious because they do not want to get into a "he said, she said" situation with members. The focus is on "necessary" expense. The best thing to do is read your plan documents and see if root canal is a covered expense. Forget about the ERISA issue, it is not the point with their response.

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Guest scheim
Actually, most plans will answer the same way, (We can't tell you if it will be covered until afterwards."), or at least they should. They are being cautious because they do not want to get into a "he said, she said" situation with members. The focus is on "necessary" expense. The best thing to do is read your plan documents and see if root canal is a covered expense. Forget about the ERISA issue, it is not the point with their response.

Actually, I AM concerned with ERISA, My root canal was just an example (I probably should have come up with something that is not so clear whether it was covered or not). I am reviewing the claims procedure of an SPD of a plan, and the example was just illustrating my question. Does a plan that refuses to tell you if something is covered violate ERISA Section 503 because it doesn't have a procedure in place to handle "urgent claims."

If the answer is to "read your plan documents and see if _______ is a covered expense," as you say, why is there a need for claims procedure, at least with post-service claims?

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No, it does not violate ERISA. What the plan should be do is tell you what specific expenses would be covered, without referring to your particular situation. Let me give you an example. If you call and ask if a certain expense is an eligible expense, the plan administrator can look at the spd and determine yes or no. Let's assume that the expense is an eligible expense. Now you say to them, "I am having that expense incurred, is it covered? They can answer "we cannot tell you if it is covered until after" and still be within the law. The reason is they have no way of knowing if it meets other requirements, such as necessity, appropriate provider, etc.

I know it sounds strange, but it is a legitimate answer to give.

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