Summary Plan Description for In and OON Providers: How to Read, Analyze & Interpret an SPD

Thomas J. Force, Esq.

Thomas J. Force, Esq.

As a state and federally licensed attorney in both New Jersey and New York, Mr. Force has over 30 years of experience in the healthcare and insurance industries. His success as a Wall Street insurance litigator and his tenure as General Counsel for a New York-based Accident and Health Insurance Company where he served as Chief Compliance...
Read More
60 Mins
Thomas J. Force, Esq.

Why is the Summary Plan Description Important to Out-of-Network Providers

As an employer sponsoring ERISA-covered health and welfare plans, you are legally obligated to communicate the terms of the plan to participants in a summary plan description (SPD). But many plans operate under poorly worded SPDs and leave their sponsors open to liability. You should know how to create a clear and comprehensive SPD so that you can avoid expensive litigation in the future.

In this web session, expert speaker Thomas Force will help you understand what a summary plan description is, what information ERISA requires to be included in the document, and the importance of the information to providers – particularly out of network (OON) providers. You will also learn how to understand the language and terminology of the summary plan description, how to ascertain the important information to determine the amounts allowable, what your appeal rights are, and what procedures are medically necessary.

After attending this session, you’ll be able to read, analyze, interpret, and summarize a summary plan description. You’ll also be able to correctly determine the allowable amounts and medically necessary procedures. Plus, you’ll know your appeal rights – and how to maximize your payment of claims.

Webinar Objectives

After attending this webinar, you will learn:

  • The difference between the Summary Plan Description and the Plan Document and the Insurance Certificate.
  • What to look for in the SPD which is important to increase claim reimbursement.
  • How to determine what services are considered medically necessary.
  • The internal appeal rights afforded to the patient/provider.
  • How eligible expenses are determined.
  • About external appeals and independent review of claims.
  • What the maximum allowed amounts are based on and calculated.
  • The importance of requesting the plan documents.
  • What documents and information they are entitled to from the insurance company and employer.

Webinar Agenda

  • What is a Summary Plan Description?
  • What is a Plan Document?
  • What is an Insurance Certificate?
  • Why is the Summary Plan Description important to out-of-network providers in particular
  • How are allowed amounts determined?
  • What are the patient's/provider's appeal rights?

Who Should Attend

  • In and Out-of-Network Providers
  • The staff of Medical Professionals and Facilities 
  • Healthcare billing companies
  • Healthcare Attorneys
To access this webinar, kindly reach out to our customer support team at

We also Recommend

Streamlining the Credentialing Process: Avoiding Common Pitfalls!
Streamlining the Credentialing Process: Avoiding Common Pitfalls!
Stephanie Thomas, CPC, CANPC, COSC | 60 Mins
Live | HealthCare

View More

Let us inform you about everything important directly.