Group health plans that are self pay by employers or unions and administered by a third party administrator(TPA) are required to maintain the right to appeal by the claimant. Even by signing the payment over to the provider group, the DOL has determine that this does not constitute signing over your right to appeal. Group health plans are allowed to set their own "reasonable" standards as to what a plan participant is required to do to sign over the rights to another party(including their physicians office.) If these are DOL regulated plans, and the TPA is following DOL guidelines to the letter, you might be out of luck. I've worked for a plan like this, and for that plan it is actually a serious violation of DOL regulations to make exceptions to normal plan guidelines based on an individuals circumstance. If you are trying to get something paid that simply isn't within the plan guidelines, you're probably out of luck. If you are trying to get something paid that you feel is within plan guidelines, or you were mislead by something posted on the payer website, or a customer service contact with the payer you have three options(assuming that we are talking about a group health plan administered as part of an ERISA trust, which based on the appeal rejection language, it sounds like we are) One, if the appeal meets the DOL definition of urgent, meaning the patient will suffer permanent injury or uncontrolled pain without the recommended treatment and a physician attests to this, the normal submission guidelines will be waived(meaning you can take over the claimants rights to appeal), and an appeal must be accepted and processed within 72 hours. Your other two options are to tell the patient they must appeal the service themselves, as they are the claimant, the payer has to respond to them within 15 days for pre-service denials and 30 days for post service denials. Or, you can contact each payer, find our their "reasonable" standards for assigning the right to appeal, go through that process and the same standards for when the claimant directly appeals will apply. There are even more guidelines than this, but this should be a good place to get started.
Here is the link to the specific DOL guidelines i'm referring to. They are for the payer but if this is the scenario you find yourself in, this should help you know the way they are processing your appeals.
https://www.dol.gov/sites/default/f...esponsibilities-under-a-group-health-plan.pdf
Sorry this is so long, but in the complicated world of insurance, self funded group plans are in my opinion one of the more complicated type to navigate.