Urgent Care Claims And The Employment Retirement Income Security Act: What You Need To Know

Posted on: 19 November 2015

If your employer offers you a health plan, federal law treats the insurance as a type of employee benefit. As part of this, the policy falls under the remit of the Employment Retirement Income Security Act (or ERISA), which sets out to protect your benefits. In certain cases, your insurer must treat a claim through one of these plans as an urgent care claim. Find out what this means, and learn more about the regulations that ERISA imposes.

Types of claim

There are several types of claim you may need to consider under your group health plan. For example, a pre-service claim applies where you need to ask the insurer for authorization before you can proceed with any type of treatment.

An urgent care claim is a type of pre-service claim where the insurer must work to shorter timescales to give you a decision about your treatment. This process exists because there are some circumstances where it is dangerous for you to wait too long before you receive any treatment.

The evidence required

For your insurer to consider an urgent care claim, you will need a report from your doctor. ERISA does not impose a specific list of conditions that this description covers. Instead, insurers must treat a claim under the urgent care rules if a physician says that they need to follow this procedure.

Examples would include:

  • A condition that could threaten your life if you don't get treatment quickly
  • A condition that could cause a further permanent disability if you don't get prompt treatment
  • A condition that subjects you to severe pain that you cannot adequately manage without the care you have asked for

You must make sure that the information you give to the insurance company comes from a qualified physician with the knowledge necessary to accurately assess your health.

Timescales permitted

According to ERISA, if you submit an urgent care claim, the insurance company must respond within a certain period. The insurer must approve (or deny) your claim within 72 hours of receipt, but you may receive a decision sooner than this. What's more, if the insurer needs more information, they must tell you within 24 hours of receipt of the claim. They must also give you no less than 48 hours to respond.

An insurance company can only extend the 72-hour window with your permission. The insurer may make the final decision verbally to meet the timescale, but you must also receive written notification.

Appealing a decision

Of course, there are various reasons why your insurer may decline an urgent care claim. For example, the plan may not cover the condition you are suffering from, or you may only have part-coverage according to your symptoms. Nonetheless, if you think the insurer's decision is wrong and breaches the terms and conditions of the plan, you can appeal.

As with the original claim, your insurer must respond quickly to an appeal if you decide to submit one. While the insurer must deal with normal pre-service appeals within a thirty-day period, you must have a response to an urgent care appeal within 72 hours from the time the insurer receives your request to review the claim.

The insurer must respond to your appeal request in writing. If the insurer continues to deny your claim, they must explain the reasons why this has happened, referring specifically to any provisions in the plan that would uphold this decision. With most insurers, you can appeal a second time if you believe the decision is unfair or illegal.

If the insurer still fails to honor the claim, you can report the complaint to your regional Employee Benefits Security Administration (EBSA) office. At any stage in the process, it is also a good idea to contact a trained attorney, as he or she can make sure you follow the correct process to get the insurer to pay your claim.

American insurers must process urgent care claims in a certain way, to cut the risk of further illness or disability to the claimant. If your insurer won't pay your urgent care claim, contact an experienced ERISA attorney from a firm like Iler and Iler for more advice.