Claims and Appeals Review Procedures Under ERISA
This section provides general information about the claims and appeals procedures applicable to the plan under ERISA.
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Please note: Participants should also review the applicable benefit plan document. In the event of a conflict between the applicable benefit plan document and this SPD, the terms of the benefit plan document will prevail.
Filing Claims & Appeals
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You must file any claims to establish your eligibility to participate in the plan with the company by contacting the plan administrator.
If you have a claim related to a specific coverage, treatment or benefit, even if your question relates to eligibility for plan benefits, follow the instructions and procedures for Claims for Benefits below.
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Unless otherwise provided in the applicable benefits plan document (or related summary), you must file a claim for benefits within twelve (12) months following the date the service was rendered. You should file your claim for benefits with the applicable claims administrator, as identified in the applicable benefits plan document (and/or related summary).
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Unless otherwise provided in the applicable benefits plan document (or related summary), your claim for benefits will be processed under the procedures described below. Self-funded benefits will be decided by the applicable claims administrator, and insured benefits will be decided by the applicable insurer.
Note: the procedures listed below are default claims procedures and apply only when the applicable benefits plan document (and/or related summary) doesn’t provide for a specific claims procedure. If the benefits plan document (and/or related summary) does provide a specific claims procedure, you must follow the procedure in order for your claim for benefits to be processed.
Disability Plan Claims
(Includes claims under short-term disability plan and long-term disability plan)
Notice of the plan's determination will be sent within a reasonable time period but not longer than 45 days from receipt of the claim.
If the claims administrator determines that an extension is necessary due to matters beyond control of the plan, this time may be extended 30 days. You will receive notice prior to the extension that indicates the circumstances requiring the extension and the date by which the claims administrator expects to render a determination. Before the end of this extension period, you will be provided with either a written decision on your claim or notice that the period to decide your claim is being extended for an additional 30 days.
If the extension is necessary to request additional information (i.e., you have not provided the information necessary to decide the claim), the extension notice will describe the required information, and the extended time period for deciding your claim will be tolled beginning with the date the plan notifies you of the missing information, and will not begin running until you provide the necessary information, provided that the claims administrator may choose, if you do not provide the requested information within 45 days of the date of the request, to decide your claim based on the information then received.
If the period to decide your claim is extended, you will be notified of the reasons for the extension; when it is expected that the decision on your claim will be made; an explanation of the standards on which entitlement to benefits is based; any unresolved issues preventing a decision; and any additional information needed to resolve those issues.
Non-Disability Welfare Plan Claims
Urgent Claims
Any claim for medical care or treatment where making a determination under the normal timeframes could seriously jeopardize your life or health or your ability to regain maximum function, or, in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that could not adequately be managed without the care or treatment that is the subject of the claim.
Notice of the plan's determination will be sent as soon as possible taking into account the medical exigencies, and in no case later than 72 hours after receipt of the claim.
If your urgent claim is improperly filed or missing information needed for a coverage decision, you will be sent notification within 24 hours of receipt of the claim, at which point you will have 48 hours to provide additional information.
You may receive notice orally; in which case a written notice will be provided within 3 days of the oral notice.
If you request an extension of urgent care benefits beyond an initially determined period and make the request at least 24 hours prior to the expiration of the original determination, you will be notified within 24 hours of receipt of the request.Pre-Service Claims
A claim for services that have not yet been rendered and for which the plan requires prior authorization.If your pre-service claim is filed properly, a claims determination will be sent within a reasonable period of time appropriate to the medical circumstances, but no later than 15 days from receipt of the claim.
If your pre-service claim is improperly filed or missing information needed for a coverage decision, you will be sent notification within 5 days of receipt of the claim.
If the claims administrator determines that an extension is necessary due to matters beyond control of the plan, this time may be extended 15 days. You will receive notice prior to the extension that indicates the circumstances requiring the extension and the date by which the claims administrator expects to render a determination. If the extension is necessary to request additional information, the extension notice will describe the required information, and you will be given at least 45 days to submit the information. The claims administrator then will make its determination within 15 days from the date the plan receives your information, or, if earlier, the deadline to submit your information.Post-Service Claims
A claim for services that already have been rendered, or where the plan does not require prior authorization.Notice of the plan's determination will be sent within a reasonable time period but not longer than 30 days from receipt of the claim.
If the claims administrator determines that an extension is necessary due to matters beyond control of the plan, this time may be extended 15 days. You will receive notice prior to the extension that indicates the circumstances requiring the extension and the date by which the claims administrator expects to render a determination. If the extension is necessary to request additional information, the extension notice will describe the required information, and you will be given at least 45 days to submit the information. The claims administrator then will make its determination within 15 days from the date the plan receives your information, or, if earlier, the deadline to submit your information.Concurrent Care Claims
A claim that arises when there is a reduction or termination of ongoing care.You will be notified if there is to be any reduction or termination in coverage for ongoing care sufficiently in advance of such reduction so that you will be able to appeal the decision before the coverage is reduced or terminated, unless such a reduction or termination is due to a plan amendment or termination of the plan.
Concurrent care claims may fall under any of the other three categories mentioned above, depending on when the appeal is made. -
If you disagree with the decision on a claim, you (or an authorized representative) may file a written appeal with the plan. Unless otherwise stated in the applicable benefit plan document (or related summary), you must file your appeal within the deadline set out in the chart below. Requests for appeals should be sent to the address specified in the denial notice. If you do not appeal on time, you may lose the right to file suit in a state or federal court, as you will not have exhausted internal administrative appeal rights (which is generally a requirement before suing in state or federal court).
You will have the opportunity to submit written comments, documents, or other information in support of your appeal, and you will have access to all documents that are relevant to your claim. Your appeal will be conducted by a person different from the person who made the initial decision. No deference will be afforded to the initial determination.
If your claim involves a medical judgment question, the claims administrator will consult with an appropriately qualified health care practitioner with training and experience in the field of medicine involved. If a health care professional was consulted for the initial determination, a different health care professional will be consulted on appeal. Upon request, the claims administrator will provide you with the identification of any medical expert whose advice was obtained on behalf of the plan in connection with your appeal.
A final decision on appeal will be made within the time periods specified below.
Note: the procedures listed below are default claims procedures and apply only when the applicable benefits plan document (and/or related summary) doesn’t provide for a specific claims procedure. If the benefits plan document (and/or related summary) does provide a specific claims procedure, you must follow the procedure in order for your claim for benefits to be processed.
Disability Plan Claims
(Includes claims under short-term disability plan and long-term disability plan).
You must submit your appeal within 180 days of the date of your initial denial notice.
You may also send written comments or other items to support your claim. You may review and receive copies, free of charge, of any non-privileged information that is relevant to your request for an appeal. You may also request the names of medical or vocational experts who provided advice about your claim. The appeal review will include any written comments or other items you submit to support your claim.
The person conducting the review will be someone other than the person who denied the claim and will not be subordinate to that person. The person conducting the review will not give deference to the initial denial decision.
Notice of the plan's determination on appeal will be sent within a reasonable time period but not longer than 45 days from receipt of the request for appeal.
If the claims administrator determines that an extension is necessary due to matters beyond control of the plan, this time may be extended 45 days. You will receive notice prior to the extension that indicates the circumstances requiring the extension and the date by which the claims administrator expects to render a determination on the appeal. If the extension is necessary to request additional information (i.e., you have not provided the information necessary to decide the appeal), the extension notice will describe the required information, and the extended time period for deciding your claim will be tolled beginning with the date the plan notifies you of the missing information, and will not begin running until you provide the necessary information, provided that the claims administrator may choose, if you do not provide the requested information within 45 days of the date of the request, to decide your appeal based on the information then received.
To the extent that new or additional evidence or rationales are considered by the claims administrator in the course of the appeal, they may not be relied upon or used as a basis for denial of the appeal unless you are first given notice or such new or additional evidence or rationales, along with a fair opportunity to respond. Hence, you will be provided, free of charge, with such new or additional evidence or rationale as soon as possible and sufficiently in advance of the date on which the appeal must be decided.
Non-Disability Welfare Plan Claims
Urgent Claims
You must submit your appeal within 180 days of the date of your initial denial notice (or first level appeal notice, for second level appeals).
You will be notified of the determination as soon as possible, taking into account the medical exigencies, but no later than 72 hours after receipt of the claim.
Pre-Service Claims
You must submit your appeal within 180 days of the date of your initial denial notice (or first level appeal notice, for second level appeals).
For both the first and second levels of appeal of a pre-service claim, you will be notified of the determination within a reasonable period of time taking into account the medical circumstances, but no later than 15 days from the date your request is received (30 days if there is only one level of appeal).
Post-Service Claims
You must submit your appeal within 180 days of the date of your initial denial notice (or first level appeal notice, for second level appeals).
For both the first and second levels of appeal of a post-service claim, you will be notified of the determination within a reasonable period of time, but no later than 30 days from the date your request is received (60 days from the date if there is only one level of review).
Second Level of Appeal
If a participant is dissatisfied with an appeal decision on a claim, he or she may:
- For urgent care claims, file a second level of appeal, and receive notification of a decision not later than 36 hours after the appeal is received.
- For pre-service or post-service claims, file a second level of appeal within 60 days of receipt of the level one appeal decision, and receive notification of a decision not later than 15 days (for pre-service claims) or 30 days (for post- service claims) after the appeal is received.
If a participant does not agree with the final determination on review, he or she has the right to bring a civil action under Section 501(a) of ERISA, if applicable.
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If your claim or appeal is in part or wholly denied, you will receive notice of an adverse benefit determination that will:
- state specific reason(s) for the adverse determination;
- reference specific plan provision(s) on which the benefit determination is based;
- describe additional material or information, if any, needed to perfect the claim and the reasons such material or information is necessary (initial claim only);
- describe the plan's claims review procedures and the time limits applicable to such procedures (initial claim only);
- include a statement of your right to bring a civil action under section 502(a) of ERISA following appeal;
- state that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim for benefits;
- describe any voluntary appeal procedures offered by the plan and your right to obtain information about such procedures (appeal only);
- disclose any internal rule, guidelines, or protocol relied on in making the adverse determination (or state that such information will be provided free of charge upon request);
- if the denial is based on a medical necessity or experimental treatment or similar limit, explain the scientific or clinical judgment for the determination (or state that such information will be provided free of charge upon request);
- include information sufficient to identify the claim involved, including, as applicable, date of service, health care provider, and claim amount;
- include, as applicable, the denial code and corresponding meaning;
- include, as applicable, a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning and treatment code and its corresponding meaning;
- describe the claims administrator's standard, if any, used in denying the claim;
- describe the external review process, if applicable;
- with regard to disability claims, describe the basis for disagreeing with or not following the views presented by you to the plan of health care professionals who treated you and vocational experts who evaluated you, the views of medical or vocational experts whose advice was obtained on the plan’s behalf in connection with your benefit denial (regardless of whether the advice was relied on in making the benefit denial), and any Social Security Administration disability determination regarding you (provided such determination has been presented to the plan); and
- include, as applicable, a statement about the availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman established under health care reform laws to assist individuals with internal claims and appeals and external review processes.
For initial claims, you also will receive notification of approval if your claim is an urgent or pre-service claim. For appeals, you also will receive a notice if your appeal is approved.
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For medical benefits, you may have the right to request an independent review with respect to any claim that involves medical judgment or a rescission of coverage. Your external review will be conducted by an independent review organization not affiliated with the plan. This independent review organization may overturn the plan’s decision, and the independent review organization’s decision is binding on the plan. Your appeal denial notice will include more information about your right to file a request for an external review and contact information. You must file your request for external review within four months of receiving your final internal appeal determination. Filing a request for external review will not affect your ability to bring a legal claim in court. When filing a request for external review, you will be required to authorize the release of any medical records that may be required to be reviewed for the purpose of reaching a decision on the external review. See your benefit plan document (and/or related summary) for more information.
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You may not bring a lawsuit to recover benefits under this plan until you have exhausted the administrative process described in this section and/or as listed in your benefit plan document (or related summary). No action may be brought at all unless brought no later than one (1) year following the date of a final decision on your claim for benefits, unless a shorter period is provided in your benefit plan document (or related summary), in which case that time period controls. All legal action commenced under the plan must be brought in the federal court of proper jurisdiction in the Commonwealth of Virginia.