I have just received this information from a TPA client. Please check out the bolded language on how PPO’s are trying to dictate plan terms and claims process.

Eligibility Verification. Client shall maintain during normal business hours a procedure for prompt verification of a Covered Person’s enrollment in a Benefit Plan. Client will use best efforts to provide current eligibility/compensability information to Contract Providers. Notwithstanding, the parties agree that: (a) verification of eligibility is not a guarantee of benefits and (b) benefits for Covered Services shall be paid in accordance with the provisions of the applicable Benefit Plan. Client agrees that after confirmation by Contract Provider of a Covered Person’s eligibility, Client may not deny payment for Covered Services performed under the terms of this Agreement which are medically necessary.

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This entry was posted by cmonfils on Thursday, January 27th, 2011 at 1:26 pm and is filed under PPOs. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.