Re: Question about employer's partially self-funded insurance plan

[Guest guest]

I'm not sure at what point you have to wait before you can go

forward, I would go ahead and call your Human Resources dept ASAP and

find out the protocol.

Natasha

> Hi,

>

> I know this type of insurance (employer's self-funded plan) has

been discussed on

> here before and I am looking for some guidance from those who may

have this type

> of plan. I know that at the end of all appeals we do not have the

right to ask for a

> review with the state insurance board as they do not get involved

with this type of

> private, self-funded plan. Our plan document does lay out the

appeals process with

> the claims administrator (the insurance company doing the

administration of the

> plan) but it also mentions that the plan administrator (the

employer) has the complete

> discretion and authority to determine the benefits we are entitled

to receive.

>

> So, it seems that the employer can override any denial by the

insurance company. Is

> this the case? If so , at what point do you ask the employer to do

this? Is it after all

> appeals with the insurance company or at some earlier time? If

anyone has knowledge

> of, or experience with this type of situation I could certainly use

some guidance.

>

> Thanks,

> Mark ('s dad)

[Guest guest]

I'll second what natasha said. Let us know what they say.

Dustie

> > Hi,

> >

> > I know this type of insurance (employer's self-funded plan) has

> been discussed on

> > here before and I am looking for some guidance from those who may

> have this type

> > of plan. I know that at the end of all appeals we do not have the

> right to ask for a

> > review with the state insurance board as they do not get involved

> with this type of

> > private, self-funded plan. Our plan document does lay out the

> appeals process with

> > the claims administrator (the insurance company doing the

> administration of the

> > plan) but it also mentions that the plan administrator (the

> employer) has the complete

> > discretion and authority to determine the benefits we are

entitled

> to receive.

> >

> > So, it seems that the employer can override any denial by the

> insurance company. Is

> > this the case? If so , at what point do you ask the employer to

do

> this? Is it after all

> > appeals with the insurance company or at some earlier time? If

> anyone has knowledge

> > of, or experience with this type of situation I could certainly

use

> some guidance.

> >

> > Thanks,

> > Mark ('s dad)

[Guest guest]

Mark,

Sorry I missed this the first time. I'm in the same boat. My insurance denied because of a contract exclusion. Our policy says we have to appeal to insurance first - not sure why in this case because an exclusion is an exclusion. So anyway appealed and was denied. I found out right before Thanksgiving that my appeal package was sitting on the desk of someone in corporate HR. So, I can't get too nasty because I work for these people on the other hand if they come back with another denial they will be hypocrites because they talk about keeping good health practices and preventative care all the time.

To make a long story short - yes your company can choose to pay. They can treat it a number of different ways - they can grant you a bonus, they can cover it under medical, etc. My employee had a set appeals process for going past the insurance administrator. Check with your HR people, they should know your appeals process. I work for a huge multi-national company (I won't mention their name but they sponsor the rainbow warriors in NASCAR). I actually considered using the Connecticut law against them. I.e. they provide all US employees the same coverage. If I lived in CT I would be entitled to coverage under the law if na were referred by a craniofacial (this appears to be a flaw in the CT law - why not let peds do the referring??). Not sure exactly how this applies to self-insured but it's worth a try.

HTH Feel free to email me off-line.

Re: Question about employer's partially self-funded insurance plan

I'm not sure at what point you have to wait before you can go forward, I would go ahead and call your Human Resources dept ASAP and find out the protocol.Natasha> Hi,> > I know this type of insurance (employer's self-funded plan) has been discussed on > here before and I am looking for some guidance from those who may have this type > of plan. I know that at the end of all appeals we do not have the right to ask for a > review with the state insurance board as they do not get involved with this type of > private, self-funded plan. Our plan document does lay out the appeals process with > the claims administrator (the insurance company doing the administration of the > plan) but it also mentions that the plan administrator (the employer) has the complete > discretion and authority to determine the benefits we are entitled to receive.> > So, it seems that the employer can override any denial by the insurance company. Is > this the case? If so , at what point do you ask the employer to do this? Is it after all > appeals with the insurance company or at some earlier time? If anyone has knowledge > of, or experience with this type of situation I could certainly use some guidance.> > Thanks,> Mark ('s dad)For more plagio info

[Guest guest]

Hi Mark,

We have Cigna POS insurance through my husband's employer and it is

fully funded by them. Our helmet was denied once by Cigna, so we

appealed to the Medical Review Institute of America (MRIoA) per

Cigna's instructions in our denial letter. MRIoA denied our helmet

also, so we appealed to my husbands employer per MRIoA's

instructions in the denial letter. His employer has an appeals

committee made up of employees, with the help of consulting medical

experts, that review the case. That committee has the authority to

reverse the previous denials by MRIoA and Cigna.

The only way we got to the point of having his employer (the plan

administrator) review our denials was to follow the denial process

from Cigna to MRIoA to the employer. My guess is that we couldn't

have circumvented that process, but I'm not positive. If I were

you, I would call the benefits department of the employer and find

out exactly what the process is for expediting an approval through

the plan administrator.

This has been a very lengthy process for us, but thankfully we

decided to pay for the helmet ourselves and worry about getting

insurance coverage for it later. Had we waiting for the insurance

to cover the helmet, we would still be waiting today - many months

later - because we are still waiting to hear from his employer

regarding reimbursment for the helmet expense. If there is any way

you can afford it financially to get the helmet now rather than wait

for the insurance to cover it, I would strongly urge you to do so.

If not, just be 's advocate and push back on that insurance

company and your employer to cover the helmet.

I hope this information helps.

Best of luck to you -

Sunnie

Riley, 14 months, STARband grad 6/11/02 - Today!!

> Hi,

>

> I know this type of insurance (employer's self-funded plan) has

been discussed on

> here before and I am looking for some guidance from those who may

have this type

> of plan. I know that at the end of all appeals we do not have the

right to ask for a

> review with the state insurance board as they do not get involved

with this type of

> private, self-funded plan. Our plan document does lay out the

appeals process with

> the claims administrator (the insurance company doing the

administration of the

> plan) but it also mentions that the plan administrator (the

employer) has the complete

> discretion and authority to determine the benefits we are entitled

to receive.

>

> So, it seems that the employer can override any denial by the

insurance company. Is

> this the case? If so , at what point do you ask the employer to do

this? Is it after all

> appeals with the insurance company or at some earlier time? If

anyone has knowledge

> of, or experience with this type of situation I could certainly

use some guidance.

>

> Thanks,

> Mark ('s dad)

[Guest guest]

Hi Mark! I basically wanted to 2nd all the advice from Sunnie.

We have United Healthcare EPO (ins through my DH's employer - Alltel -

they are self-funded.) I would DEFINATELY contact your HR dept. They

should be able to tell you exactly what steps to take. Ours said we

HAD to appleal to UHC first, then could appeal directly to the

company. Unfortunetly, it took us from May - Dec to get UHC to

respond to our appeal. (I had to send it in twice - certified, return

receipt both times.) In the end, I basically called DH's human

resources dept and told them I NEEDED AN ANSWER and UHC was just

ignoring us. They finally put me through to their " Alltel Advocate "

at the insurance company. I spoke with her for about 1/2 hr and we

got our letters stating that our boys' DOC bands (3 of them) would be

paid at 100% (less our $25 co-pay ea.) within 3 wks. It was my

understanding that if we did have to appeal straight to DH's company

that they could override any denial by the insurance company, like

you stated.

Good Luck,

mom to Nolan, DOC banded 3/03-7/03 & , DOC banded 3/03-7/03,

8/03-12/03, 17 months old & big brother, , 4 yrs

> > Hi,

> >

> > I know this type of insurance (employer's self-funded plan) has

> been discussed on

> > here before and I am looking for some guidance from those who may

> have this type

> > of plan. I know that at the end of all appeals we do not have the

> right to ask for a

> > review with the state insurance board as they do not get involved

> with this type of

> > private, self-funded plan. Our plan document does lay out the

> appeals process with

> > the claims administrator (the insurance company doing the

> administration of the

> > plan) but it also mentions that the plan administrator (the

> employer) has the complete

> > discretion and authority to determine the benefits we are

entitled

> to receive.

> >

> > So, it seems that the employer can override any denial by the

> insurance company. Is

> > this the case? If so , at what point do you ask the employer to

do

> this? Is it after all

> > appeals with the insurance company or at some earlier time? If

> anyone has knowledge

> > of, or experience with this type of situation I could certainly

> use some guidance.

> >

> > Thanks,

> > Mark ('s dad)