Variations
If a person is treated for back pain in the lookback of a pre-existing claim with a California Situs, what do you need to know to determine if it is pre-existing?
Was it a diagnosed condition.
The pre-ex-investigation manages what for the company?
risk
Notice of the ongoing pre-x investigation.
Why it is important to document the pre-x review outcome in the action plan?
This is helpful for anyone reviewing the claim to know what pre-existing conditions were found.
Other than a condition being diagnosed, what is another of the two differences in a California Variations pre-existing investigation?
either :
1. the exclusion of the “reasonably prudent person” wording
2. three-prong (i.e., 3/3/12) provision is no longer permitted
In New York, it is not permitted to deny benefits for a pre-existing condition. What do New York plans do instead?
What is the first thing you need after the interview to start your pre-ex-investigation?
Medical authorization
anything reasonable, stroke, heart attack, fracture after mva
Can you refer a pre-existing review to clinical along with a request to assist with determining if restrictions and limitations are supported?
yes, with a detailed referral specifying both needs.
In New York MetLife is not able to deny a claim for a Pre-Existing condition. What does New York allow for Pre-existing conditions instead?
MetLife permits a plan to limit benefits for a specific period of time.
the exclusion of reasonable prudent person wording.
and the three-pronged provision is not permitted
Name three things that should be on the pre-existing review templet
any three:
pre-x info (doh, ied, dlw, ddc)
pre-x provision
disabling conditions
pharmacy profiles
calls to providers and medical requested
conditions confirmed pre-extisting
outcome of review
Do you continue the pre-ex-investigation if you have already approved the claim after ruling out the primary disabling condition is not pre-existing?
yes
We request medical records from all providers the claimant treated with in the lookback.
When can MetLife deny a claim for Pre-existing conditions in New York?
when the funding is not fully insured
what other types of plan funding are there other than fully insured
Self-funded (administrative services agreement)
limited funding (when the funding arrangements for a claim change from fully insured to self-funded)
After all information is received, what steps are taken to complete your pre-ex-review?
review the medical records/pharmacy records
and if unclear request NC/PCS assistance
You would advise the claimant of the outcome of the investigation
any
California variations require an additional piece to the pre-existing investigation. What is this piece?
the claimant received medical treatment, care or services or took prescribed medication during the “look back period”, it must have been for the same diagnosed condition as the Disability.
If the plan is self-funded.
Why is a back injury not necessarily a good disabling condition to rule out a pre-existing condition from a specific accident or incident?