Claims denied pending pre-existing information.

[Guest Damien]

Does anyone see a problem with a self-funded health plan using the following procedure in regard to claims possibly subject (based on diagnosis and date of hire) to pre-existing exclusion?

Claim is determined (based on diagnosis and date of hire)to be possibly subject to pre-ex exclusion.

Claim is denied, and request for certificate of creditable coverage and/or questionaire on treatment in the lookback period is sent to member.

When certificate info and or questionaire is received, denied claim is recalced if warranted.

I am not terribly familiar with the new regs concerning timely payment, improper denial of claims, appeals, etc. and was wondering if they had any bearing on the procedure described above.

Would it make any difference if the information had been requested at enrollment, but not received yet?

[Kirk Maldonado]

I'm not terribly familar with the HIPAA regulations, but I don't think that the procedure you described complies with them.

[KIP KRAUS]

Why wouldn't you request the certificate of creditable coverage day one if you have a pre-ex provision?

I see no reason why a plan couldn't deny a claim based on a pre-ex if no ceritificate was given to the plan Administrator at enrollment. However, if a new participant hasn't recieved it from his former employer I would re-open the claim for redetermination upon reciept of the certificate.

[Guest KGibson]

Make sure that you have expressed or referenced this procedure in your SPD. I would further state in your initial request for the certificate of creditable coverage that claims may be denied pending the receipt of this information. This is the "normal" process of claims administration for this situation in all self funded plans that I have directed since HIPAA. By the way, you know what the HIPAA letters really mean? Have I Punished Administrators Adequately?

[Kirk Maldonado]

To raise the spectre of another problem impacting this situation, does anybody know if the recently finalized SPD regulations require explicit disclosure of (1) the pre-existing condition limitation and (2) the procedure for implementing and appealing the imposition of a pre-existing condition limitation?

P.S. I'm pretty sure that the new regulations have a delayed effective date, so they wouldn't impact this particular situation, but it could potentially come into play in the future.

[Guest KGibson]

I found some further info that may be helpful. One media release dated 11/20/2000 expressed requirements for: full decision of the plans claim procedures and more info about the reasons for denied claims and criteria and rules applied. I found this at: http://www.dol.gov/dol/pwba/public/media/p...ss/pr112000.htm

I found the dol issued reg. at:

http://www.dol.gov/dol/asp/public/regs/fed...snew/2000029765

This is effective Jan 20, 2001 and is applicable the first day of the second plan year beginning on or after 1/22/01.