Practice Management Alert

Use this letter template to request information from a noncontracted carrier so you can appeal an underpaid claim under ERISA

This letter may be all you need to secure payment: Use this letter template, provided by Steven Verno, CMBS, compliance director for the Medical Association of Billers based in Las Vegas, to request the information you'll need to fight an adverse benefit determination (ABD) under ERISA. See "Want To Collect From Noncontracted Payers? File an ERISA Appeal" for a full explanation of how ERISA can help you to file a successful appeal with a noncontracted carrier when it underpays your claim.

Date

Name of Carrier Address City, State, ZIP

RE: (Name of Patient)

Dear Claims Manager,

We are noncontracted providers who provided medically necessary care and services to your client, named above. As a courtesy to your client, a claim was submitted to you in a timely manner. As you can see from the attached Explanation of Benefits form, your company paid us less than 100 percent of our usual and customary provider charges.

According to the Department of Labor, payment of less than 100 percent of our usual and customary charges is determined to be an adverse benefit determination per the Employee Retirement Income Security Act (ERISA). See Title 29 USC 25, Part 2560-503-1(m)(4).

On behalf of the patient, and in accordance with Title 29, USC 18, 1024(b)(4) we are therefore making the following demands:

1. We hereby demand that you provide us with the Name, Business Address, Business Phone Number and Facsimile Number of the Plan Fiduciary.

2. We hereby demand that you provide us with a true copy of the member's Summary Plan Description.

3. We hereby demand that you provide us with the name and specialty of the person who has made this adverse benefit determination.

4. We hereby demand that you provide us with true copies of all documents used to make this adverse benefit determination.

You have thirty (30) days to comply with these demands. Per ERISA, Title 29 USC 18, 1332 (c), failure to do so could result in a $100-per-day fine. We will also file a complaint with the Department of Labor. We wish you to know that if these demands are not met, we will balance bill your member, which is allowed per ERISA. I am sure you are aware that ERISA preempts State Law (See Title 29 USC 18, 1144a).

Very truly yours,

Appeals Department