Appeals

Medical

You can appeal Aetna’s adverse benefit determination. Aetna will assign your appeal to someone who was not involved in making the original decision. You must file an appeal within 180 calendar days from the time you receive the notice of an adverse benefit determination. You can appeal by sending a written appeal to Member Services at the address on the notice of adverse benefit determination, or you can call Member Services at the number on your ID card.

You need to include:

Your name
The employer’s name
A copy of the adverse benefit determination
Your reasons for making the appeal
Any other information you would like us to consider

Another person may submit an appeal for you, including a provider. That person is called an authorized representative. You need to inform Aetna if you choose to have someone else appeal for you (even if it is your provider). You should fill out an authorized representative form telling us that you are allowing someone to appeal on your behalf. You can get this form by contacting Aetna. You can use an authorized representative at any level of appeal.

You can appeal an adverse determinate two times under this plan. If you appeal a second time you must present your appeal within 60 calendar days from the date you receive the notice of the first appeal decision.

If your appeal is denied a second time, you may have the right to an external review. For more information, please refer to Aetna’s Evidence of Coverage for your medical plan option on the HR website.

Pharmacy

If you do not agree with the denial of your claim, you have 180 days to file an appeal. If you have questions about how to file a pharmacy appeal, you should call the Capital Rx Customer Care telephone number, (833) 599-0942. The submission of an appeal does not guarantee coverage.

Appeals must be made in writing to Capital Rx. You should state the reasons why you do not agree with the denial or partial denial and provide any supporting documentation. The Capital Rx claims administrator will then review the information and provide a written decision within 60 days. If necessary, this period may be extended for an additional 60 days, and you will receive written notice of this extension. Supporting documentation, such as a physician’s letter and/or a FDA MedWatch form completed by your physician, could be requested as part of the appeal process.

Dental

You have the right to two levels of appeal if a claim is denied in whole or in part. An appeal must be made in writing by you or an authorized representative such as a provider. To initiate an appeal, contact Delta Dental at 800-223-3104

Initial Appeal: All requests for review must be made within one hundred eighty (180) calendar days following denial of a claim. You have the right to review, during normal business hours, any documents held by Delta Dental pertinent to the denial. You may also submit written comments or supporting documentation concerning the claim to assist in Delta Dental's review. Delta Dental's response to the initial appeal, including specific reasons for the decision, will be communicated within thirty (30) calendar days after receipt of the request for the appeal.

Second Level Appeal: If you disagree with the response to the initial appeal of the denied claim, you have the right to a second level appeal. A request for a second level appeal must be submitted to Delta Dental within sixty (60) calendar days after receipt of Delta Dental's response to the initial appeal. The manner in which to seek a second appeal will be included in with the letter informing you of a first level appeal denial. Delta Dental will communicate its final determination to you within thirty (30) calendar days from receipt of the request.

Vision

Second Level Appeal: If you disagree with the response to the initial appeal of the denied claim, you have the right to a second level appeal. A request for a second level appeal must be submitted to Delta Dental within sixty (60) calendar days after receipt of Delta Dental's response to the initial appeal. Delta Dental will communicate its final determination to you within thirty (30) calendar days from receipt of the request.

Flexible Spending Account

If your claim is denied, in whole or in part, you will be notified in writing within 30 days of the date your claim was received of the reason(s) your claim has been denied. These reasons include but are not limited to ineligible expenses per IRS regulations, submission of claims incurred prior to or after the benefit effective or termination date, incorrectly completed reimbursement form or no supporting documentation, or unacceptable supporting documentation. If you feel a claim was incorrectly denied, you should contact Benefit Express at 877-837-5017 and ask for a review of your claim. Your appeal must be made in writing within 180 days of the denial. If you do not appeal on time, you will lose the right to appeal the denial and the right to file suit in court. Your written appeal should state the reason(s) that you feel your claim should not have been denied. It should include any additional facts and/or documents that you feel support your claim. Your claim will be reconsidered, and you will receive written notice of the decision within 60 days. All interpretations of the Plan Administrator will be final and binding.

Disability

If MetLife denies your short-term or long-term disability claim, you may appeal the decision. Upon your written request, MetLife will provide you free of charge with copies of documents, records and other information relevant to your claim. You must submit your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLife's decision.

Appeals must be in writing and must include at least the following information:

Name of Employee
Name of the Plan
Reference to the initial decision
An explanation why you are appealing the initial determination

As part of your appeal, you may submit any written comments, documents, records, or other information relating to your claim. After MetLife receives your written request appealing the initial determination, MetLife will conduct a full and fair review of your claim. Deference will not be given to the initial denial, and MetLife's review will look at the claim anew. The review on appeal will take into account all comments, documents, records, and other information that you submit relating to your claim without regard to whether such information was submitted or considered in the initial determination. The person who will review your appeal will not be the same person as the person who made the initial decision to deny your claim. In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny your claim. If the initial denial is based in whole or in part on a medical judgment, MetLife will consult with a health care professional with appropriate training and experience in the field of medicine involved in the medical judgment. This health care professional will not have consulted on the initial determination and will not be a subordinate of any person who was consulted on the initial determination.

MetLife will notify you in writing of its final decision within a reasonable period of time, but no later than 45 days after MetLife's receipt of your written request for review, except that under special circumstances MetLife may have up to an additional 45 days to provide written notification of the final decision. If such an extension is required, MetLife will notify you prior to the expiration of the initial 45 day period, state the reason(s) why such an extension is needed, and state when it will make its determination. If an extension is needed because you did not provide sufficient information, the time period from MetLife's notice to you of the need for an extension to when MetLife receives the requested information does not count toward the time MetLife is allowed to notify you of its final decision. You will have 45 days to provide the requested information from the date you receive the notice from MetLife. If MetLife denies the claim on appeal, MetLife will send you a final written decision that states the reason(s) why the claim you appealed is being denied and references any specific Plan provision(s) on which the denial is based.

Administrative

To file an appeal related to enrollment or coverage, please visit the Tools & Forms page on the HR website and complete the Benefit Appeal Request form.

Tuition Assistance

To file an appeal related to the denial of an employee or dependent tuition assistance application, please review this helpful guide.