Claims for Benefits

Claims Determinations

Flexible Spending Account – Dependent Care

If your claim under the FSA – Dependent Care is denied in whole or in part, you or your beneficiary will receive a written notice providing:

  • the specific reason or reasons for the denial;
  • reference to the specific provisions of the plan on which the denial was based;
  • a description of any additional information needed to process the claim; and
  • an explanation of the claims review (appeals) procedure and the time limits applicable to such procedure, including your right to bring a civil action under Section 502(a) of ERISA if your claim is denied on review.

The notice will be furnished to you within 90 days after receiving your claim.  However, if special circumstances require more time for processing your claim, you will be notified in writing before the initial 90 days is up.  The notice will explain why an extension is necessary and the date a decision is expected.  In no event will an extension go beyond 90 days after the end of the initial 90 days.

Flexible Spending Account – Health Care

If your claim under the FSA- Health Care is denied in whole or in part, the following procedures will apply, depending upon the type of claim:

Post-Service Claims are those claims that are filed for payment of benefits after medical care has been received. Claims for benefits under the FSA – Health Care will always be Post-Service Claims.  If your Post-Service Claim is denied, you will receive a written notice from P&A Group within 30 days of receipt of the claim, so long as all necessary information was provided with the claim.  If circumstances beyond the control of the Plan require more time for processing your claim, federal law permits one extension of up to 15 days.  You will be notified of any extension before the initial 30 days are up.  The notice will explain why an extension is necessary and the date a decision is expected.

If an extension of the decision period is necessary because additional information is needed to decide your claim, then the notice of extension will specifically describe the required information and you will have 45 days to provide it. If all needed information is received within the 45-day time frame, P&A Group will notify you of the determination within 15 days after the information is received.  If you don’t provide the needed information within the 45-day period, your claim will be denied.

If your claim is denied in whole or in part, you will receive written notice of:

  • 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; and
  • if the initial 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.