If the provider you've chosen is out of network, there's a good chance we can help get get approval in writing from your plan administrator. But this must be done in advance of surgery, not after the surgery has been done.
Source: EBSA Feb. 27, 2019
The U.S. Department of Labor (DOL) released an information letter addressing an entity’s ability to act as an authorized representative for participants and beneficiaries in ERISA group health plans. In part, this is what we do all the time when working with individual consumers where the employer has not yet contracted with SurgeryShopper.com as part of their benefit program.
The letter responds to an inquiry made on behalf of an entity that serves as a “patient advocate and healthcare claim recovery expert for plan participants and beneficiaries, both at the initial application stage and when claimants appeal turn-down letters (called “adverse benefit determinations”) from their health benefit plan or TPA case manager.
Contrary to popular belief, that’s not the end of the journey.
The letter explains that the DOL’s claims procedure regulations set forth minimum requirements for employee benefit plan claims procedures under ERISA. Under the regulations, participants and beneficiaries have the right to appoint authorized representatives to act on their behalf in connection with an initial claim, an appeal of an adverse benefit determination, or both. When you engage our services to help coordinate your care, we’ll talk with your employer to obtain necessary authorization to use the program and perhaps even get your deductible and copayment waived and get you help to pay for the travel and accommodation costs at the treatment destination. This service is included in our standard case management fee.
A plan cannot preclude claimants from designating an authorized representative of their own choosing, but generally may establish reasonable procedures for determining whether an authorized representative has been designated.
Urgent care claims (A special rule for urgent care claims requires plans to recognize any health care professional with knowledge of a claimant’s medical condition as the claimant’s authorized representative.)
Any procedures for designating an authorized representative must be set out in the plan’s claims procedures and in the SPD (or a separate document that accompanies the SPD).
When an authorized representative such as the SurgeryShopper.com concierge team has been designated to act and receive notices on a claimant’s behalf, the plan should direct communications and notices to the assigned case manager at SurgeryShopper.com as the authorized representative unless the claimant directs otherwise. Both the claimant and the plan should make clear the extent of the authorized representative’s authority.
SAMPLE FORM LETTER WORDING
Here is an example of the simple form that can be used (in most cases) to designate SurgeryShopper.com as your advocate and authorized representative with your employer-sponsored health benefit program:
YOUR NAME
Insured’s Name (if different)
Address
Phone
DESIGNATION OF AUTHORIZED REPRESENTATIVE
I, <PATIENT’S NAME>, do hereby designate the case management team at SurgeryShopper.com to the full extent permissible under the Employee Retirement income Security Act of 1974 (“ERISA”) and as provided in 29 CFR 2560-503-1(b)4 to otherwise act on my behalf to pursue claims and exercise all rights connected with my employee health care benefit plan, with respect to any medical or other health care expense(s) incurred as a result of the services I receive from the above named provider. These rights include all rights to act on my behalf with respect to initial determinations of claims, to pursue appeals of benefit determinations under the plan, to obtain records, and to claim on my behalf such medical or other health care service benefits, insurance or health care benefit plan reimbursement and to pursue any other applicable remedies.
_______________________________
Patient’s Signature
_________________________________
Patient’s Printed Name
_________________________________
Date
_________________________________
