Full Service Appeals Processing
CAFS has a full-service approach to processing final claim appeals for various benefit plans. To accomplish this, in accordance with the requirements involved, CAFS:
- Employs highly skilled, educated professionals.
- Claims process and plan document details are evaluated and customized for the specific plan sponsor and the terms of the benefit plan for which CAFS is providing individual claim appeal processing.
- CAFS maintains and continually improves its process and review systems based on developments in the legal landscape and any changes to plan terms.
- CAFS coordinates with plan sponsors, outside professionals and consultants, medical review companies, and claims administrators as needed or warranted.
Each individual claim appeal is processed in accordance with the plan sponsor's specific needs in a customized, complete integrated process that includes the following actions:
- CAFS fully investigates the facts and compiles a complete administrative record, including the plan document and SPD.
- CAFS assesses the procedural status of the appeal, dockets all deadlines and documents the procedural history of the claim.
- CAFS evaluates the applicable plan terms and standards.
- CAFS communicates with the claimant regarding the claims procedures under the plan, consistent with the plan and its sponsor’s requirements.
- CAFS reviews and assesses the factual findings in the record and gathers additional facts as may be warranted by the circumstances from internal staff, outside professionals as may be needed, including actuaries (pension), medical reviewers (medical and disability) and sponsor’s counsel if needed.
- CAFS evaluates new facts, considers additional evidence to be obtained and coordinates the pursuit of this additional information with the claimant and the plan sponsor.
- CAFS completes the development of the administrative record under the applicable claims procedure.
- CAFS analyzes the factual record under the terms of the plan.
- CAFS makes analytic findings based upon the facts in the administrative record and the plan terms.
- CAFS creates a thorough, detailed, written decision, and notifies the claimant and the sponsor.
- CAFS responds to any follow up communications from the claimant.
- CAFS supports the sponsor's efforts to enforce any adverse decision, including assisting in litigation, discovery, and any further needs of the sponsor relative to the claim process.
The use of CAFS provides complete advantages for the plan sponsors, internal staff and the claimants themselves. As a result of this quality approach, plan sponsors are at an advantage when they employ CAFS to act as the independent ERISA fiduciary to process ERISA plan final claim appeals. The investment in this independence provides a clear return, because it provides the quality and skilled service that is needed to relieve the burdens on human resource or other staff, eliminates conflict of interest, reduces the likelihood of process issues, and brings a skilled and capable independent third party to improve final claim appeal processing, which solidifies the financial integrity of these important plans for all concerned.
To learn more, please contact us for details of how CAFS is a better alternative for the processing of claim appeals for all of your employee benefit plans.
Please note that CAFS does not provide any legal brokerage, asset management or accounting services and does not hold or control any plan assets. top