How do I handle an appeal as a non-ERISA self-funded group member?
ERISA does not affect the appeal rights for these groups and the Insurance Commissioner has held that self-funded groups are not eligible for PA250. Thus, Blue Cross Blue Shield of Michigan (BCBSM) will offer the first and second level of appeals to these groups.
BCBSM offers ERISA groups with Administrative Service Contracts the following three options on handling appeals:
- Option A: BCBSM handles both levels of appeals for pre-service, urgent care and post-service claims. This means BCBSM handles all administrative work associated with any member appeals.
- Option B: BCBSM handles the first level and the group handles the second level. BCBSM is willing to provide administrative support for handling these appeals but requires at least 21 calendar days lead time to research the appeal and provide a response to the group. The group is then responsible for communicating the appeals decision to the member within the 30-day timeframe allowed under the DOL regulations.
- Option C: The group handles both levels of appeals. When a group chooses this option, BCBSM is unable to provide the comprehensive services as in Options A and B. Although the group retains the ability to interpret their health care plan, BCBSM does not have the ability, on the group's behalf, to resolve many of the issues that a group may currently encounter.