[Teresa]

Harrison,
My claim is with Workers Compensation, so it does not pertain to my case. I provided this information for those that are covered under a Self Insured Health Plan. I think the information can be used to assist others on this forum for the following reasons:
1. ERISA is very specific about the process and time frames for requesting coverage. The time frames are different for different situations depending on whether it's pre or post care. Members of the forum need to follow the time frames very carefully especially during the appeals process.
2. ERISA governed plans supersede any state statue unless the state statue provides for greater benefit to the patient. Therefore the Insurance Commissioner, etc. are of little help when appealing.
3. ERISA governed plans have very specific rules regarding appeals. What is interesing is that the Adjustors at most TPAs really don't understand ERISA very well. The patient can use the link to the DOL Website or other ERISA Information sites and find specific rules to include in their appeal. This can be very intimidating to the TPA. These information sites also have Consumer Help Tips on what to include in your appeal, etc.
4. The Summary Plan Document is another key piece of your appeal. ERISA has very specific rules about what should be in the SPD, the time frames for advising members of changes to the plan, etc. Patients should obtain and read the SPD and use any information in it to support the appeal.
5. The final decision on appeals lies with the employer because they are self insured. It is wise to provide any information to support your appeal to the employer. The employer is often not aware of your appeal. There are many players in the game: Employer, TPA, PPO, Case Management, Utilization Review. It is important to know which of the players is most influencing your claim. It is important to obtain each players data. You can't fight their data if you don't know what their data says.

I specifically posted the ERISA information in response to CindyLou and Laurie. However, I felt it would be helpful to others on the forum. The first question they should ask their employer is: "Are we self insured?" The rules are very different for self insured plans verses a commercial plan.

One of the pieces of data that you should use is the cost. Find out the cost of fusion or other procedure that they will authorize and compare it to the cost of ADR. Many times if you show them the cost benefit they will authorize. Don't forget to include costs for hospital, physicians, anesthesiologist, lost time from work, cost of any short or long term disability payments as well as future medical costs. The point that you want to make is that ADR cost is equal to or less than the alternate procedure cost. Your goal here is make the employer question the TPA as to why they are denying payment for the procedure if the cost is less. Your employer should be questioning the TPA as to why they can substantiate a denial for ADR when the alternative procedure costs the same or more.

Harrison, please let me know if I can be of further assistance regarding Self Insured Plans.