Providers Should Not Overlook Their Right to Request Documents When Appealing Adverse Benefit Determinations to ERISA Plans

From the article:

When providers try to appeal adverse benefit determinations to the administrators of health and benefit plans governed by the Employee Retirement Income Security Act (ERISA), all too often the response to the appeal is simply non-informative. It is not unusual for a provider’s appeal to be met with a form letter containing no more than a sentence or two that the original benefit determination is being upheld because “benefits were paid in accordance with plan terms,” or some similarly vague statement. This rarely assists providers in understanding the basis for the benefit determination because provider often do not know the plan terms.