ERISA Appeals

[French]

We have a question about how to address a response to a 2nd level appeal that has been sent to us (the employer) for a self-insured health plan. The appeal package was prepared by an attorney on behalf of the subscriber who is appealing a denied claim for his dependent (age 17). Should the response be addressed to the member (the dependent) and sent to the attorney with a copy to the subscriber? Should the response be addressed and sent to the subscriber since he is the one appealing with a copy to the attorney? The initial claim denial through the health plan was addressed to the member (the dependent) but sent to the attorney.

Appreciate any advice.

[J Simmons]

I would send to all 3 just to cover my bases, but at least to the subscriber and attorney. The 17 year old is likely not emancipated, and thus the subscriber acts for the 17 year old member.

[French]

Thanks for your comments. I may not have clarified my specific question which perhaps is even more complicated as the attorney references both the subscriber and his spouse in the appeal package. So should the salutation be addressed to the dependent, subscriber, subscriber and spouse or the attorney? This happens to be a somewhat contentious appeal so we are trying to be very careful.

[J Simmons]

You might want to check the specific plan's language, but I would think that the attorney and subscriber (I assume is the employee in the ERISA plan) ought to suffice under the claims procedure regs. It might be different if the subscriber and spouse are divorced and the spouse has custody over the 17 year old, then adding the spouse and mailing to the spouse would make sense. It in part depends on whether the subscriber is the legal custodian of the 17 year old.

Since your response to the appeal will likely have HIPAA protected health information, you might request a waiver and limitation on use/dissemination signed by all before providing the appeal response to them.

Get the advice of counsel for the specific situation before proceeding--particularly since this is a contentious situation.