This is a very good flowsheet and explanation that Cathy has posted above.
Having a summary of “major payer policies” works but will bite you if you aren’t careful. Remember that fully funded plans have to follow the policy of the carrier. Self-funded do not.
Remember: self-funded=ERISA=ASO=TPA=self-insured= can do WHATEVER THEY WANT. You cannot rely on the carrier’s policies (ie: United) even though it says "united on the card. This is where the flow sheet is invaluable. According to Chip, this is very regional and many areas of the country may not have very many of these. Where I am (Texas), these represent >75% of commercial plans.
On the other hand: fully funded=state-regulated=department of insurance=DOI=non-ERISA. These folks have to follow national policy and are generally easier to verify.
We have found that the elig and verification process for many of these the self-funded plans is just so bad right now. Some you can’t even get through. Others you get through to, and they don’t even understand your question. We therefore have occasionally made “best estimates” and sent claims without being able to verify telemed eligibility. When we have to wait for 30 min for verification, it is time prohibitive. While inexcusable, it is what it is. Good luck out there. #wildwildwest