How is a claim for benefits approved or denied?
A. We recommend that a medical doctor sign a form that gives a description of the disability and the ICD-9 code. The member stating that he/she is in fact disabled should also sign the form. The form is then submitted to the plan and payments begin. A quality assurance check is to have a relationship with the employer so that the plan can be informed of members who are soon to be out of sick leave or paid days off (PDO) (thus indicating a likelihood of going on disability) or are out on disability. As long as a claim falls into the category of “allowed” per the plan documents, denials are held to a very minimum. Provisions for a review committee should be included in the plan documents.
