Fully insured plan
The local Blue licensee bears the claims risk as the insurer. State insurance rules and, where applicable, external review through the state regulator may apply.
Funding Structure
When a Blue Company Administers a Self-Funded Employer Plan
If an employer self-funds the health plan, the Blue company may act as an administrator rather than the insurer. The plan documents and applicable federal or other governing law determine the appeal process.
Insurer vs. Administrator
Two Very Different Roles
Self-funded (ASO) plan
The employer or plan sponsor bears the claims risk. The Blue company acts as a third-party administrator, processing claims according to the employer's Summary Plan Description.
Plan Sponsor and Administrator
Who Actually Controls the Appeal
For a self-funded plan, the employer or a trust (such as a union or association trust) acts as the plan sponsor and generally holds fiduciary responsibility. The Summary Plan Description identifies the plan administrator and appeal process, and some self-funded arrangements delegate final appeal authority back to the Blue company, while others retain it with the employer or a board of trustees. The SPD, not the Blue plan's general commercial materials, controls.
ERISA and Its Exceptions
Federal Law Usually Governs, With Notable Exceptions
Most private-employer self-funded plans are governed by the Employee Retirement Income Security Act of 1974 (ERISA). Under ERISA's preemption framework, these plans are generally not subject to state insurance laws in the same way a fully insured plan is, though the Affordable Care Act separately requires a parallel federal external-review process for many plans. Governmental and church plans are a distinct category: they're generally exempt from ERISA entirely, and their appeal procedures, deadlines, and external-review rights are dictated by the specific plan document and applicable state or municipal law instead.
State External-Review Limitations
State Programs May Not Apply to Self-Funded Plans
State-mandated external-review programs, such as an Independent Medical Review or a state Department of Financial Services external appeal, generally apply to fully insured coverage regulated by that state. Self-funded ERISA plans typically follow a federal external-review process instead. Confirm funding status before assuming a state program applies to your case.
BlueCard Implications
Self-Funded Plans Can Still Use BlueCard
A self-funded employer plan can still use a Blue company's network through BlueCard for out-of-area care. That doesn't change the funding analysis: the Home Plan's role as administrator and the employer's role as plan sponsor still control the appeal, separate from any Host Plan involvement in local claim processing.
What Remedy Support Needs to Verify
Documents That Confirm the Funding Structure
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The Summary Plan Description or plan document
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Whether the card or EOB is labeled "administered by" a Blue company
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The plan sponsor's name
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Whether the plan expressly adopts ERISA procedures
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The denial notice's stated appeal process and deadline
Privacy Notice
Don't Upload Plan Documents Here
This page explains what matters, not somewhere to submit it. Don't upload your SPD, insurance card, or other case documents to a public page. Use Remedy Support's secure intake to submit documents for a case-specific review.
Next Step
Ready to Continue to Secure Intake?
Once you've located your plan documents, Remedy Support can review them alongside your denial and determine whether your case fits our current service.
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