With the DOL's deadline for adopting new claims procedures quckly approaching, I was wondering what is happening in the market place with self-insured plans. Have your clients been appointing their TPA's as fiduciaries with authority to make final benefit appeal decisions under a self-insured plan, or are they authorizing the TPA's to make the initial determination, and maybe a first level appeal decision, but retaining final appeal responsibility? Have the TPA's agreed to be the fiduciary?

I know that Blue Cross/ Blue Shield will take responsibility for all levels of the appeal, but what if the TPA is not BC/BS? Any sense of what is happening?

Most of our TPA's have been retained (at an additional
cost) to make a first level determination. Our trustees
will be hearing and deciding any final appeals. I have seen
very few TPA's willing to make the final decision.

Hi

A typical arrangement is for the TPA to make the initial claims determination, and handle the first level of appeal, with the employer providing a second level of appeal.

The regs require that a claimant be allowed to appeal an adverse benefit determination to a named fiduciary. If the first level of appeal is to the TPA, and the TPA does not have final claims authority, and refuses fiduciary status, is that level of appeal even permissible?

Can a plan require the employee to appeal to the TPA (not a named fiduciary) before the employee is eligible to bring the appeal to the employer/named fiduciary?

Is the only solution to get the TPA to agree to fiduciary status?

Thanks.

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