Wiki ERISA... has anyone gone this route for self funded plans? (NY state)

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suki_26

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If need be we know we can appeal with the insurance commissioner for long outstanding and unpaid claims. Buut self funded plans are a totally different thing. I hate to keep beating this to death but I am sooo fed up with EMBLEM. They are now denying covid swabs for the HIP patients saying we are out of network and an authorization was required. After sending appeals even screen printing their website showing where they say these services will be covered IN or Out of network, we still get the exact same cookie cutter response. " The claim was processed correctly"

As an AR rep I love a good justified fight but this is getting out of control. Has anyone gone through the appeal route with ERISA? In all these years I've never had to actually do more than threaten it It almost looks like we would have to get our lawyers involved in something like that and I'm not so sure the Doctors want to do that.

This next level appeal I'm about to send them is going to have enough information that, if actually read, should get my claims processed very quickly. The problem is they are not even reading these appeals. If I get another cookie cutter denial I need to have a next step.

Thanks for any info
 
Our local self-funded plans are either schools or unions. I have good success with just calling the plan itself instead of appealing through the claims processor.
 
HAHAHAHA I'm sorry trust me we have gone every normal route, called, uploaded or questioned online, sent spread sheets, spoken to supervisors. Emblem has become a spoiled child that does whatever they want. I've been doing this a while and they used to be one of the better ones. No longer and I cant find that we really have any recourse other than to accept it. That doesn't sit well with me.
 
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