orthobiller2017
Networker
I work for a third party billing company. One of our clients performed an out of network surgery on a patient whose cpt code didn't require prior auth. One code was paid at ucr and the other denied as not medically necessary which in fairness is consistent with policy of coverage for procedure. We appealed and it was upheld. My managers are asking what we can do further but this was final internal level and self funded plan. In all my years I have never done an erisa appeal and have been informed this is actually initiated by patient not provider to DOL
Further, if the policy was specific would this even be amendable to erisa. None of the provider appeals speak of any external review options but imagining this would be in the patient's paperwork not providers?
Further, if the policy was specific would this even be amendable to erisa. None of the provider appeals speak of any external review options but imagining this would be in the patient's paperwork not providers?