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Fiduciary Status of Claims Reviewer


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We have a service provider who does first-level appeals. This service provider asserts that they are not a fiduciary because the plan also has a second-level appeal. The service provider says there is caselaw out there supporting this position, but I have not found it.

Is anyone familiar with such caselaw?

Does anyone know whether a second-level appeal would relieve this provider of fiduciary status?

Since claims are required to be reviewed by the appropriate fiduciary, is it even possible to allow a service provider to review claims if the service provider refuses to be a fiduciary?

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We have a service provider who does first-level appeals. This service provider asserts that they are not a fiduciary because the plan also has a second-level appeal. The service provider says there is caselaw out there supporting this position, but I have not found it.

Is anyone familiar with such caselaw?

Does anyone know whether a second-level appeal would relieve this provider of fiduciary status?

Since claims are required to be reviewed by the appropriate fiduciary, is it even possible to allow a service provider to review claims if the service provider refuses to be a fiduciary?

The service provider is correct that it is not a claims fiduciary (it may be a fiduciary for other reasons) to the extent that it does not make final claims adjudications. In such a case, it is only performing ministerial functions.

Some claims administrators will agree to be the final arbiter of claims but in my experience they will charge an exorbitant fee to do so. I'm not sure what you mean by "Since claims are required to be reviewed by the appropriate fiduciary."

A question I have that I have not seen addressed is to what extent that PPACA's independent review requirement will change the traditional medical plan fiduciary model.

This is probably something you should speak to counsel about.

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