Guest guest Posted December 16, 2003 Report Share Posted December 16, 2003 RIley graduated today? Congratulations Riley!!!!!!!!! Angie and Jenna(STARband grad 1/21/03) Re: Question about employer's partially self-funded insurance plan 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 - SunnieRiley, 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)For more plagio info Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 22, 2007 Report Share Posted January 22, 2007 Poor Baby!!! Sorry she got that tummy flu - we all got it right after new years! BLECH! As far as the shift - some can be normal - but mention it to the ortho at the appt! Jen and LuliRight Tort - Plagio - Hanger Band Grad - CA Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.