What You Should Know About Filing Your Health Benefits Claim

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.

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.

Obtain A Copy Of Your Summary Plan Description (Often Referred To As An SPD)

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.

Filing A Claim For Benefits

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.

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.

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.

Waiting For A Decision On Your Claim

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 whether the claim is for urgent care and 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.

What To Do If Your Claim Is Denied

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.

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.

The Review Of Your Appeal

Your plans’ 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 whether it involves urgently needed care or whether the claim is filed before the medical care is provided or after.

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.

What To Do If Your Appeal Is Denied

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 Employee Benefits Security Administration concerning your rights under ERISA.

Know Your Plan And Your Rights And Responsibilities

As noted above, it is important that you know 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.

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.

For further information on your rights and responsibilities under ERISA, contact EBSA’s toll-free publications request number at 1.866.444.EBSA (3272). You can view available publications on the EBSA Web site at www.dol.gov/ebsa.