Periodically, subscribers have asked whether they are entitled to request copies of insurance documents from carriers.

For example, as a provider, you may wish to request a copy of a recoupment provision, subrogation provision, coordination of benefits provision, or other similar type of contract clause.

Before requesting copies of documents, a couple of points should be understood. First, you should distinguish whether you are looking for a provision from the "provider agreement," or from the underlying "health benefits plan," or both. The provider agreement is the agreement signed between provider and the insurance entity. A group health benefits plan is the agreement signed between insurance entity and employer. In the case of recoupment, we recommend that you get a copy of the recoupment provisions from both types of documents. Obviously, if you are "out-of-network," the provider agreement will not apply to you. In such cases, you will most certainly need to get a copy of the underlying health benefits plan provision.

Secondly, many carriers, when asked for a copy of the relevant provision, will direct providers to their medical policy bulletins which the carriers post on their web sites. These bulletins amount to nothing more than opinions by the carriers as to what the controlling agreements may say. We have seen many situations where the bulletins actually conflict with the provider agreements and underlying health benefits plans. If a carrier directs you to their online bulletins, our suggestion is that you make it clear that you are wanting copies of provisions from the controlling documents, not from the online opinions.

Thirdly, whether you know it or not, many health benefits plans are governed under a federal law called "ERISA." ERISA gives you a right to request plan documents and to receive them within 30 days. Carriers who fail to provide the documents upon request can be penalized up to $110 per day.

A sample letter for requesting health benefit plan provisions and managed care provider agreement provisions has been loaded in the demand letters section of our web site. You will find it under the subsection entitled, "ERISA."

For more information regarding how to request plan documents, please feel free to contact us.