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If you are an employee or family member of an employee
who receives health benefits from a health plan provided through
employment in the private sector, a federal law, the Employee Retirement
Income Security Act (ERISA), protects you. Among the protections, ERISA
sets standards for administering these plans. Those standards require
plans to give you important information about the plan and to have a fair
process for handling benefit claims.
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Below are steps you should take to file a benefit claim and what to do if
your claim is denied. It is especially important to know your rights under
your plan and the law if your benefit claim is denied.
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The first step you should take - even before you are ready to file a benefit
claim - is to carefully read your plan's summary plan description. This is a
document which your plan administrator must furnish to you after you join
the plan. You can also request a copy from your plan administrator. The SPD
gives you a detailed summary of your plan - - how it works, what benefits it
provides, and how they may be obtained (the process for filing your claim).
The summary plan description is also required to describe your rights and
protections under ERISA.
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ERISA requires every plan to have procedures for filing a claim and to tell
you what those procedures are. As noted above, this information must be
included in the summary plan description.
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All plans have rules governing what benefits they offer
and how to apply for them. For example, some plans may require you to file a
claim (seek authorization) before you can receive medical treatment. Some
plans may have special rules for urgent care. For other plans, you must
submit a claim for reimbursement after receiving and paying for the care
yourself.
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To avoid a delay in processing your claim or a denial of
your claim, you should follow the steps outlined in your plan's summary plan
description when filing your claim. If you cannot find the steps, or if you
cannot understand them, you should consult your plan administrator or
contact the Department of Labor's Employee Benefits Security Administration
(EBSA) for help in understanding your rights.
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Your plan's claims procedure should state the time within which the plan
must provide you with a decision on your claim. Be sure to look for these in
your SPD. When you submit a claim to your plan, note the date and keep track
of the time as you wait for a decision. Some plans may have different time
periods depending on the nature of the benefit claim - such as if the claim
is for urgent care or whether the claim is filed before medical care is
received or after. Some plans' procedures allow the plan to extend the time
period. Your plan's claims procedure should provide for the plan's
notification to you of the plan's decision on your claim for benefits. If
you do not get a response from your plan within the specified time period,
contact your plan administrator.
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Your plan may deny a claim for many reasons. For example, you may not have
met the plan's annual deductible, the requested treatment may be something
the plan says is not covered or not medically necessary, or you may not have
filed enough information for the plan administrator to process the claim.
Look for the reason and other information provided in the notice of denial
so that you can determine if you want to appeal the decision.
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When you are notified that your claim has been denied,
your plan administrator also must tell you how to appeal your denied claim
for a full and fair review. Your plan will specify the number of days you
have to file your appeal and may provide for extensions of that time period.
When appealing a benefit denial, be sure to include any additional
information or evidence supporting your claim or required by your plan's
procedure, and get it to the specified person and address within the
permitted time period.
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Your plan's claims procedure should also specify the time period for the
plan to make a decision on your appeal. Note the date when you submit your
appeal and be aware of this waiting period. The waiting period for decisions
on appeals may also be different depending upon the type of claim that was
initially filed - such as if the claim is for urgent care or whether the
claim is filed before the medical care is provided or after.
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When the decision is made on your appeal, you must be
notified of the decision. If your claim is denied, you must be told the
reason and the plan rules upon which the decision was based in writing in a
manner you can understand. If you do not receive notification of the
decision within the waiting period provided for in your plan, you can assume
your claim has been denied after it was reviewed.
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If you disagree with the final decision on your appeal or if your plan fails
to make a timely decision, you have the right under ERISA to file suit in
court to get your benefits. The plan's explanation of your denial should
describe this right. You also may wish to get in touch with the Department
of Labor's Pension and Welfare Benefit Administration concerning your rights
under ERISA.
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As noted above, it is important that you know what your plan's claims
process. If you fail to follow the plan's process, including meeting
required deadlines, your ability to challenge the plan's decision in court
could be affected.
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If your plan's procedures do not give you the rights
provided for under ERISA, or if your plan fails to follow its procedures,
you may have the right to bring an action in court to enforce your rights.
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For further information on your rights under ERISA,
contact the Employee Benefits Security Administration's Toll-Free Employee
& Employer Hotline at 1.866.444.EBSA (3272).
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