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Appeals to Self-Funded Plans

How do I know if my plan is self-funded? Contact your benefits administrator in your human resources department. He or she will be able to tell you if you have a self-funded plan.

If you have insurance through a private, self-funded health plan, then your employer may decide to cover the procedure that is denied.  In this situation, appeal to the administrator of the health plan.  If denied again, consider appealing to the employee benefits group or the individual in your human resource department that makes decisions regarding health benefits choices.  Explain to him or her why your doctor believes it is medically necessary for you to have this procedure or service and why it is critical that it be covered.  Provide a copy of all of the supporting medical information. 

Some self-funded plans do not make procedure by procedure coverage decisions on their own, rather they defer to coverage guidelines established by the insurance company that administers or manages the plan.  If this is the case, ask your benefits contact to reach out to the insurance company to encourage the insurance company to cover the procedure or service. 

The more patients that proactively reach out to the benefits contact at your company requesting coverage for the denied procedure or service, the more reason he or she will have to work towards covering the procedure.

 

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