Claim and Appeal Timeframes for Group Health Claims

Group health claims will be reviewed and appeals processed by the applicable Plan Vendor within the time periods required by law. You may contact the applicable Plan Vendor for more information about claim procedures relating to health benefits administered by that Vendor under the Plan.  Additional information about claim and appeal procedures under a Plan Vendor’s coverage may also be available in the Plan Vendor’s benefit description.
Under ERISA claims and appeals must be decided within a reasonable time, subject to the certain maximum limits summarized as follows:

Intial Claims

After receipt of the claim, the claim must be decided no later than:
• As soon as possible but no later than 72 hours for urgent care claims
• 15 days for pre-service claims
• 30 days for post-service claims
Claimants have 180 days to appeal a denied claim.

Appeals of Denied Claims

After receipt of the request for review, the appeal must be decided no later than:
• As soon as possible but no later than 72 hours for urgent care claims
• 30 days for pre-service claims
• 60 days for post-service claims

Special rules apply for the continuation or extension of approved benefits or services to be provided over time (“concurrent care decisions”).  Individuals receiving approved care over a period of time must have an opportunity for review before benefits are reduced or terminated.  Also, urgent care requests for an extension of approved benefits must be decided within 24 hours.