Many people in Austin receive their health insurance through their employers’ health plan options. Many of these health insurance plans are governed by the Employee Retirement Income Security Act (ERISA).
Like any health insurance plan, there are different coverage limits and other restrictions. The health insurance plan will not pay for all of the medical costs that people incur. Patients or their healthcare providers will submit the bills to the insurance plan and they will need to submit a claim in order to determine whether they will receive the benefits under the plan.
The insurance plan may deny the claim or parts of the claim for a variety of reasons. These denials can be very detrimental for people needing the insurance proceeds to help pay for medical costs.
Denial and appeals process
The denial from the insurance plan must be in writing and sent to the people requesting the claims. The denial letter sent to the plan participant must specifically state the reason for the denial; the parts of the plan that the plan used to deny the claim; if additional information is needed to review the claim and how to submit an appeal of the denial.
The plan must provide patients with the details of the appeals process. It must have information on how to request an appeal, to review the relevant documentation and submit documentation with comments relating to the issue and reason for the denial. People generally have 60 days after receiving the denial letter to file their appeal. The insurance plan then generally has 60 days to issue its decision on the appeal.
It is important for Texas residents to understand the claims process under ERISA. It is also important to understand their plans and the basis for the denial. This will allow them to understand the reasons for their appeals of the denial and what information they will need to present.