ERISA appeals: why self-funded plans play by different rules.
When an employer self-funds its health plan, claims are governed by federal ERISA law, not state insurance rules — so state prompt-pay deadlines and many state appeal protections don't apply. ERISA sets its own framework: the plan document controls, you generally get a full and fair review with specific timelines, and exhausting the plan's internal appeals is the required path.
What actually matters
- Self-funded plans follow ERISA and the plan document, not state prompt-pay or state appeal law
- You can't always tell from the card — ask, or check whether the plan is administered by a TPA for an employer
- ERISA requires a "full and fair review": the plan must give the specific reason and the right to submit evidence on appeal
- Timelines are federal (e.g. defined windows for pre-service, post-service, and urgent claims) and set in the plan
- You generally must exhaust the plan's internal appeals before any external review or further action
Common questions
How do I know if a plan is self-funded?
It's not always obvious — a self-funded plan often carries a familiar carrier's logo because that carrier only administers it. Ask the employer or TPA, or look for ERISA language in the plan documents. It changes which appeal rules apply.
Do state prompt-pay laws apply to self-funded plans?
No. ERISA preempts state insurance law for self-funded plans, so state clean-claim deadlines and interest rules don't apply. Your leverage is the plan's own ERISA-mandated procedures and timelines.
Where Volari fits: Volari files each appeal under the rules that actually govern the claim — ERISA plan procedures for self-funded, state rules for fully-insured — so the appeal lands on the right track the first time.
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