Appealing a Denial of Claims for Benefits
How to Appeal a Claim Determination
If you disagree with a claim determination, you can contact P&A Group in writing to formally request an appeal. Your first appeal request must be submitted to P&A Group within 60 days after you receive the claim denial. in the case of a FSA- Dependent Care claim and within 180 days after you receive the claim denial in the case of a FSA – Health Care claim.
An appropriate, named plan fiduciary who did not make the initial decision and who is not a subordinate of the individual who made the initial decision will decide the appeal. The review will show no deference to the initial decision. As part of the review, you or your authorized representative may submit written comments, documents, records, or other information relating to the claim for benefits, and, upon request and free of charge, you or your authorized representative will be provided reasonable access to, and copies of, all documents, records and other information relevant to your claim for benefits. You may also request the identity of any medical experts consulted by the plan in connection with the initial benefit decision. The Plan fiduciary who considers your appeal will take into account all information you submit, regardless of whether it was submitted or considered in the initial decision. If your appeal is related to clinical matters, the review will be done in consultation with a health care professional with appropriate expertise in the field who was not involved in the prior determination. P&A Group and the Plan Administrator may consult with, or seek the participation of, medical experts as part of the appeal resolution process.
Flexible Spending Account – Dependent Care
P&A Group will notify you of its decision on review not later than 60 days after receiving your request for review. If special circumstances require more time to reach a decision, it will be made as soon as possible, but not later than 120 days after receiving your request. If an extension of time is necessary, you will receive a written notice explaining why an extension is necessary and the date by which a decision is expected. A denial on review will be in writing and include:
- the specific reason or reasons for the denial;
- reference to the specific Plan provisions on which the denial is based;
- a statement 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 your claim for benefits; and
- a statement of your right to bring a civil action under Section 502(a) of ERISA.
Flexible Spending Account – Health Care
You will be provided written or electronic notification of decision on your appeal within 60 days for the appeal of a Post-Service Claims. Prior to receiving a final adverse benefit determination based on new or additional evidence or rationale, you will be provided with any new or additional evidence considered, relied upon, or generated in connection with your claim, and any new or additional rationale, and you will have an opportunity to respond prior to the date the final adverse benefit determination is due. If the appeal is denied, you will receive a notice providing –
- the specific reason or reasons for the denial;
- specific reference to the Plan provisions on which the denial is based;
- if a plan rule or guideline was relied on in making the initial benefit decision, either the specific plan rule or a statement that a copy of the rule will be provided to you free upon request;
- the additional information, if any, needed to approve your claim and an explanation of why such information is necessary;
- the Plan claims review procedure, including a statement of your right to bring an action under Section 502(a) of ERISA, following an adverse determination appeal;
- if the benefit decision was based on a Plan exclusion or limit (such as medical necessity or experimental treatment), either an explanation of the basis for the determination or a statement that such explanation will be provide to you free upon request; and
- the following statement: “You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency.”
Exhausting Administrative Remedies
If your claim is denied on review, then you may bring a civil action in federal or state court. You may not commence such an action, however, until you have exhausted your administrative remedies under the Plan. Unless otherwise expressly stated in the plan document for the applicable plan, you must initiate any civil action on a claim for benefits under the Flexible Benefits Program within 12 months after exhaustion of your administrative remedies under the Plan.