Forum - Questions & Answers
Third party adminstrator question
We have recieved denials for not meeting coverage critieria through a group that is a TPA. Is it a requirment by law for the TPA to provide the physicians office access to the medical policy guidelines for services provided?
Thanks!
Third party administrator question
Do you have a contract with the TPA?
No, they don't
As we will all learn with the upcoming RAC audits, the RAC companies are allowed to have proprietary software and guidelines and are under no obligation to share it with anyone. It should be based on medical standards of care and guidelines but many ares are so grey that no guidelines exist.
Third party administrator question
Do you participate with this TPA? Do you have a contract?
Is there a medical policy for the service you are doing, that shows that another insurance allows the service for that condition, or Medicare does? That would give you a basis for appeal (if you participate) or for complaint with the insurance department, if you don't.
These third party plans are governed by ERISA, and I'm not 100% sure that the state insurance departments regulate them.
Can you give us a specific?