Forum - Questions & Answers

May 5th, 2009 - Chriss

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!

May 5th, 2009 - Codapedia Editor 1,399 

Third party administrator question

Do you have a contract with the TPA?

May 5th, 2009 -

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.

May 11th, 2009 - Codapedia Editor 1,399 

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?



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