Avoiding Self-Funded Plan Denials Through Advanced Verification
- Know the Plan Rules:
ERISA self-funded plans follow employer plan documents, not standard commercial insurance rules. - Verify Complete Plan Details:
Confirm plan type, TPA, employer sponsor, SPD, and benefit documents before the visit. - Check Custom Coverage Limits:
Review exclusions, prior authorizations, OON benefits, visit limits, and diagnosis restrictions. - Document Verification Proof:
Save plan details, screenshots, call notes, and references to support appeals. - Train Staff & Automate Checks:
Help teams identify self-funded plans and trigger PA workflows early. - Track ERISA Denials Separately:
Monitor denial reasons and create plan-specific appeal strategies.