If Your Claim Is Denied

Anonymous User
Associate
House Staff
RN (NYSNA)

If your claim for benefits is denied, in whole or in part, you will receive a written notice. This notice will include the following:

  • The specific reasons for the denial of your claim
  • The specific references in the Plan document that support those reasons
  • A description of the information you must provide to perfect your claim and the reasons why that information is necessary
  • A discussion of the procedure available for further review of your claim, including your right to file a civil action following an adverse benefit determination on review
  • If the denial relies on an internal rule, protocol or guideline, such rule, protocol or guideline, or a statement that it will be provided free of charge to you upon request
  • If the denial is based on a medical necessity or an experimental treatment, an explanation of the clinical or scientific reasoning for denial of the claim, or a statement that it will be provided to you free of charge upon request.

In the case of a denial of an urgent care claim, the notice also will set forth a description of the expedited review process for an urgent care claim.

Your Right to Appeal

You have the right to appeal a denial of your claim. You must submit a written appeal to the insurance company within 180 days after you receive the claim denial notice. In preparing your appeal, you shall be entitled to request and receive, free of charge, copies of any documents, records or other pertinent information associated with your claim. This pertinent information includes any information in the initial benefit determination that was considered or generated (even if not relied on) and the identity of any medical expert who was consulted (even if not relied on). Any of this information may be submitted for determination, even if it was not considered in the initial benefit determination.

The insurance company will conduct a full and fair review of your appeal and it will not give deference to the initial benefit determination. The appeal shall be heard by an appropriate individual (or individuals), who is not the person having made the initial benefit determination or a subordinate of that person. This reviewer on appeal also may consult with a medical professional, who was not consulted or a subordinate of any person consulted in the initial benefit determination.

If your appeal involves an urgent care claim, the insurance company shall notify you of the decision as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of your appeal. You may request an expedited appeal, which may be made either orally or in writing and allows all necessary communication between you and the administrator to take place via telephone, facsimile or other equally expeditious method.

If your appeal involves a pre-service claim, the insurance company will notify you of the decision within 30 days after receipt of your appeal.

If your appeal involves a post-service claim, the insurance company will notify you of the decision within 60 days after receipt of your appeal.

If your appeal is denied, in whole or in part, the insurance company will provide you with a notice with the following:

  • The specific reasons for the denial including the specific Plan provisions on which the denial relies
  • A statement informing you of the availability of any documents, records or other relevant information free of charge upon request
  • A description of any internal rule or protocol relied upon or a statement that any such rule or protocol will be provided free of charge upon request
  • An explanation of any voluntary appeals procedures that may be available and a statement of your right to bring a civil action
  • If the denial of an appeal is based on a medical necessity or experimental treatment, an explanation of the scientific or clinical judgment exercised or a statement that the explanation will be provided free of charge and upon request
  • The following statement: “You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what might be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency.”

Throughout the claims review procedure, you may have a personal representative act on your behalf.

Any failure on your part to comply with the request for information by the Plan Administrator or insurance company may result in delay or a denial of your claim.

The insurance company has the authority to make final decisions with respect to paying claims under the Medical Plan.

If you believe that you have been improperly denied a benefit from the Plan after making full use of the claims and appeals procedure, you may serve legal process on the Plan Administrator.