Can I Appeal the Decision of an Independent or Third-Party Administrator (TPA) if I'm Not Satisfied with Their Assessment of My Claim?

When it comes to filing an appeal for a denied claim, it is important to understand the regulations established by the Employee Retirement Income Security Act (ERISA). These regulations only apply to employee benefit plans offered by private sector employers to their employees or unions. Government programs, such as Medicaid and Medicare, are not covered by these claims procedure rules. Neither are government-sponsored benefit programs for government employees, such as the Federal Employees Health Benefits Program (FEHBP), or benefit plans offered by state or local governments to their own employees.

If you are in an urgent medical situation, you can request an expedited appeal that requires the insurance company to make a decision within 72 hours. The appeal will be reviewed for a second time by insurance company employees who were not involved in the original decision. The regulation defines a group health plan as an employee welfare benefit plan within the meaning of section 3 of ERISA (to the extent that such plan provides medical care within the meaning of section 733 (a) of ERISA). Consequently, for the purposes of the rules of claim procedure, the provision of dental benefits, whether as part of a larger wellness plan or as a standalone plan, would be subject to the requirements of the regulations applicable to group health plans.

Under the regulation, a benefit is a disability benefit, subject to the special rules for disability claims, if the plan conditions its availability for the applicant to prove their disability. It doesn't matter how the benefit is characterized in the plan, or whether the plan as a whole is a pension plan or a social assistance plan. If the claims judge must make a disability determination to decide a claim, it must be treated as a disability claim for purposes of the regulation. The Department has stated that when a single plan provides more than one type of benefit, it is intended that the nature of the benefit determines what procedural rules apply to a specific claim, rather than how the plan itself is characterized.

Consequently, plans that offer benefits conditional on determining disability must maintain procedures for requests involving such benefits that meet the requirements of regulations applicable to disability applications. However, if a plan provides a benefit whose availability is conditioned on determining disability and that conclusion is made by a separate part of the plan for purposes other than determining benefits under the plan, there is no need to apply special rules for disability claims to a request for such benefits. For example, if a pension plan provides that pension benefits will be paid to someone who has been declared disabled by Social Security Administration or under an employer's long-term disability plan, then requests for pension benefits based on prior determination that applicant is disabled would be subject to procedural rules of regulation for pension claims and not disability claims. The regulation establishes deadlines within which claims must be decided but does not address periods within which payments granted must actually be paid or services approved must actually be provided.

However, failure to provide services or benefit payments within reasonable periods after plan approval may present issues of fiduciary responsibility under Part 4 of Title I of ERISA. Whether specific practices allowed under a plan such as presenting prescription at pharmacy will constitute request for benefits regulated by rules of claim procedure and under what circumstances will depend on conditions of plan. In this sense, request for benefits is defined in § 2560 503-1 (e) as request for one or more plan benefits made by claimant in accordance with reasonable procedure for filing claims for benefits. Consequently, whether and extent presentation of prescription at pharmacy that does not exercise any discretion on behalf of plan will constitute request for plan benefit and extent will be determined by reference to procedures for submitting claims for benefits. It's not uncommon for group health plans to have agreements with preferred or network providers (e.g., pharmacies).

The Department believes that neither law nor rules of claim procedure require plans to treat interactions between participants and preferred or network providers in such circumstances as request for benefits regulated by regulation.