Our company policy requires patients to request their SPD from the employer that provides the health insurance at the beginning of care or when a change like getting a new plan occurs. We attach this document to your chart in order to have easy access to it when claims are filed. The SPD gives us the framework of your specific plan so we know how to get your claim processed without undue delays. All claims are filed electronically. In the event a claim isn't settled within 30 days or processes below anticipated levels, an appeal is promptly filed on day 31. If the claim does not process according to our expectations, an ERISA complaint will be filed with all supporting documentation we have accumulated. We strive to provide excellent service with top-rated healthcare professionals in the best of facilities; in turn, we expect to be compensated for our services. When this does not occur promptly, we proceed as directed by law to the appropriate legal authorities.
SPD and PLAN PARTICIPANTS
ERISA requires a group health plan-sponsoring employer to distribute an SPD to plan participants within 90 days of the participant’s enrollment in the plan. That would include a newly-hired employee who enrolls in the plan mid-year and any employee that elects coverage for the first time at open enrollment. Thereafter, ERISA requires the employer to automatically provide an updated SPD every five years if changes have been made to the original SPD, and every 10 years if no changes have been made. Lastly, an SPD must be provided upon an employee’s request.
Because the SPD is oftentimes the employer’s method for communicating benefits and obligations under the plan, and since benefits (and sometimes obligations) change each year, many employers distribute an updated SPD each year during open enrollment. That way, the employer can avoid any miscommunication to employees (and their dependents) regarding plan benefits.
ERISA requires plan administrators to furnish plan information to participants and beneficiaries and to submit reports to government agencies.
The following documents must be automatically furnished to participants and beneficiaries.
The Summary Plan Description (SPD) – the basic descriptive document – is a plain language explanation of the plan and must be comprehensive enough to apprise participants of their rights and responsibilities under the plan. It also informs participants about the plan features and what to expect of the plan. Among other things, the SPD must include basic information such as:
- Plan name, address, and contact information;
- What the plan benefits are;
- How to get the benefits; and
- Duties of the plan and/or employee.
- More specific information must also be provided, including:
- The plan’s claims procedure (either in the document or as separate attachment);
- A participant’s basic rights and responsibilities under ERISA (model language is provided in the SPD rules);
- Information on any applicable premiums, cost-sharing, deductibles, co-payments, etc.;
- Procedures for using network providers (if PPO/HMO) and composition of network;
- Conditions regarding pre-certification;
- A description of plan procedures governing Qualified Medical Child Support Orders (see
below); and Notices and descriptions of certain rights under the Health Insurance Portability and Accountability Act (HIPAA) and other health coverage laws, described below.
This document is given to employees within 90 days after they are covered by the plan and within 30 days of a request. Generally, SPDs also must be redistributed every 5th year. The SPD must be current within 120 days.
It is against the law for employers to withhold a Summary Plan Description. If you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor (Regional Office contact information) or contact the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210.
If you need further assistance, please contact our legal department.
Understanding Fiduciary Responsibilities
Fiduciaries have important responsibilities and are subject to standards of conduct because they act on behalf of participants in a group health plan and their beneficiaries. These responsibilities include:
- Acting solely in the interest of plan participants and their beneficiaries and with the exclusive
purpose of providing benefits to them;
- Carrying out their duties prudently;
- Following the plan documents (unless inconsistent with ERISA);
- Holding plan assets (if the plan has any) in trust; and
- Paying only reasonable plan expenses.
The duty to act prudently is one of a fiduciary’s central responsibilities under ERISA. It requires expertise in a variety of areas. Lacking that expertise, a fiduciary will want to hire someone with that professional knowledge to carry out those functions. Prudence focuses on the process for making fiduciary decisions. Therefore, it is wise to document decisions and the basis for those decisions. For instance, in hiring any plan service provider, a fiduciary may want to survey a number of potential providers, asking for the same information and providing the same requirements. By doing so, a fiduciary can document the process and make a meaningful comparison and selection.
Following the terms of the plan document is also an important responsibility. The plan document serves as the foundation for plan operations. Employers will want to be familiar with their plan document, especially when it is drawn up by a third-party service provider, and periodically review the document to make sure it remains current. For example, if a plan official named in the document changes, the plan document must be updated to reflect that change.
A fiduciary should be aware of others who serve as fiduciaries to the same plan, since all fiduciaries
have potential liability for the actions of their co- fiduciaries. For example, if a fiduciary knowingly
participates in another fiduciary’s breach of responsibility, conceals the breach, or does not act to
correct it, that fiduciary is liable as well.
In plain English, this means if the people processing the claims for your healthcare violate the law, we will see to it that they are held accountable. This includes criminal charges when warranted. If everyone does the right thing, we all win. We provide healthcare services and do not provide services without appropriate financial compensation. We prosecute unethical fiduciaries to the fullest extend of the law.
Undestanding Your Fiduciary Responsabilities Under a Group Health Plan
Maintaining The Plan’s Benefits Claims Procedure
Group health plans must establish and maintain reasonable claims procedures that allow participants and beneficiaries to apply for and receive the plan’s promised benefits. Fiduciaries must maintain the plan’s procedures. The Department of Labor issued rules setting minimum standards for benefit claims determinations for ERISA plans (including insured and self-funded plans). While many plans hire benefits professionals or insurance companies to process claims, it is important for an employer to understand the requirements before selecting a service provider who can comply with the standards.
A claim for benefits is a request for a plan benefit made in accordance with the plan’s procedures by a claimant (participant or beneficiary) or a claimant’s authorized representative. (We become a patient's authorized representative when you sign the Assignment of Benefits contract during the meeting with our financial department. This means we have legal standing with your insurance company so the company can be paid for the services provided during your care.)
Once a claim is received by the plan, the timeframe for making and providing notice of the claim determination varies based on the type of claim filed -
- urgent care, as soon as possible but not later than 72 hours after the plan receives the claim;
- pre-service claims, within a reasonable period of time not later than 15 days after the plan receives the claim;
- post-service claims, within a reasonable period of time not later than 30 days after the plan
receives the claim;
For claims that are appealed, the timeframe also varies based on the type of claim –
- urgent care claims, as soon as possible but not later than 72 hours after the plan receives the
request to review a denied claim;
- pre-service claims, within a reasonable period of time not later than 30 days after the plan
receives the request to review a denied claim;
- post-service claims, as soon as possible but not later than 60 days after the plan receives the
request to review a denied claim; and
No extensions are available for making decisions on appeals unless the claimant consents.
The notice of a claim denial, referred to as an adverse benefit determination, must contain the following information:
Specific reasons for denial (for example, not medically necessary, not covered by the plan, or reached maximum amount of treatment permitted under the plan);
A reference to the specific plan provision(s) relied upon for the denial;
- If denied for a lack of information, the notice must include a description of any additional
material(s) needed to perfect the claim and an explanation of why such additional material is
necessary;
- A description of the plan’s review procedures (for example, how appeals work);
- If used, either a description of rules, guidelines, or protocols relied upon in denying the claim,
- or that a copy of such items will be provided free upon request;
- If denial is based on medical necessity or experimental treatment or similar exclusion or
limit, an explanation of the scientific or clinical judgment for the denial, applying the terms
of the plan to the claimant’s medical circumstances, or a statement that an explanation will be
provided free of charge upon request; and
- A description of the claimant’s right to go to court to recover benefits due under the plan.
The notice of a claim denial on appeal must include the same information as noted above (except the description of the plan’s appeal process) as well as:
- A statement of the claimant’s right to receive, free of charge, relevant documents (documents
and records upon which the decision is based and other documents prepared or used during the
process); and
- A description of any voluntary processes offered by the plan to resolve claims disputes.
- The plan’s claims procedure must provide for a full and fair review of a benefit claim if a claimant files an appeal of the denial. The minimum standards for appeals are:
- Claimants must be given 180 days to file an appeal;
- A de novo review, that is, a review that affords no deference to the initial determination, must be
conducted;
- When the denial is based on determinations of whether a particular treatment, drug or other item
is experimental, investigational, or not “medically necessary,” the reviewer must consult with a
qualified health professional (and others as needed);
- No more than 2 appeals levels are allowed; and
- Mandatory binding arbitration of claims is generally prohibited. However, non-binding arbitration would be permissible if done within the required timelines.
Other prohibitions relate solely to duciaries who use the plan’s assets in their own interest or who act on both sides of a transaction involving a plan. Fiduciaries cannot receive money or any other consideration for their personal account from any party doing business with the plan related to that business.