Most patients know very little about their dental or medical insurance plans. An informed patient can be of invaluable assistance to your practice when problems arise with claims. ERISA (the Employee Retirement Income Security Act) is a federal law that protects individuals employed in the private sector by setting standards for administering those insurance plans. Those standards require plans to give you important information about the plan and to have an equitable process for handling the claims.

The following are the steps that patients should take when appealing a claim:

1. Obtain a copy of the Summary Plan Description (SPD)

The patient is entitled to a summary plan description. It gives a detailed summary of the plan – how it works, what the benefits are, and how to file a claim. The SPD is a document that the plan administrator must provide the patient when the patient joins the plan.

2. File a claim

3. Time period for a decision on the claim

The plan’s claims procedure provides the time within which the plan must provide the patient with a decision.

4. If the claim denies:

If the patient chooses to appeal, the plan administrator must tell the patient how to appeal the denied claim for a full and fair review. The plan will specify the number of days that the patient has to file an appeal and it may provide for extensions of that time period. In addition, the plan should also specify the time period for making a decision on the appeal.

5. If the appeal is denied:

The patient must be given a reason that shows the plan rules upon which the denial was made. Should the patient still disagree with the final decision or if the plan fails to make a timely decision, he or she has the right under the ERISA law to file suit in court to obtain benefits.

For further information on patient’s rights under ERISA, contact the Pension and Welfare Benefits Administration’s toll free publications hotline at 1-800-998-7542.

You may use my form or your practice can develop its own insurance information form with the information given here that can be given to insured patients. Remember – insurance plans are contracts between the patient and the insurance company. You can help your patients and your practice by informing them about their rights.

The form for notifying patients about their rights can be seen here. You must have Adobe Reader to open this file. If you do not have Adobe Reader, you may download the latest version here.