Frequently Asked Questions

Our Certified PPACA ERISA Medical Claims Appeals Specialists have over a decade of experience in appealing denied claims under ERISA rules and regulations.  In addition, we have become a national leader in the claims appeals process by participating in the nation’s first PPACA Claims Appeals Certification program. Learn More

1. A denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit. A denial can occur if a claim that is not paid at all or only in part.  A refusal to pre-certify or pre-authorize a service or procedure is also a denial.
2. A denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from the application of any utilization review. This includes any post payment or retroactive denial, such as a request for the refund of an overpayment or any “recoupments/refunds/offsets.”
3. A failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. This means any anything that is not paid on the grounds that it is not medically necessary or experimental and investigational. This covers claims that are denied because they are deemed medically unnecessary, experimental or investigational.

A simple request for “documentary information” is not an appeal. Appeals must be submitted according to the individual health plan documents and must request for a “full and fair” review of the denied claim. This means the appeal has to conform to the patient’s health plan documents as established in the summary plan description (or SPD).