Appeal a Denied Claim
Appealing a Denied Health Care Reimbursement Account Claim
If your claim for a benefit is denied, in whole
or in part, you will be provided with the
following information in writing within 30 days
after receiving your initial claim, or 45 days in
special situations:
- The reason for denial,
- The plan provisions that are the basis
for denial,
- An explanation of what other material
or information is needed and why it is
needed, and
- An explanation of the claims review
process and time limits for appealing
the determination, your right to obtain
information about those procedures,
and the right to sue in federal court.
You have the right to request certain
documentation, as required by the Employee
Retirement Income Security Act of 1974
(ERISA), which was relied on in making the
adverse determination. This will
be provided to you free of charge
upon request.
If an extension is necessary due to the need
for additional information, you will be notified
of the specific information needed. The claim
determination will be made within 15 days
from the receipt of your response.
If you disagree with the decision, you may request
a review of the decision by notifying the claims administrator in writing
within 180 days of the date you receive notice of
the denial. First level appeals should be mailed to the following address:
WageWorks Claims Appeal Board
PO Box 14053
Lexington, KY 40512*
*Be sure to provide your Duke Unique ID if asked or
prompted to provide your Social Security number. |
You will be able to examine all the materials
related to your claim, such as the plan's official
documents. The claims administrator will decide on your appeal within
30 days of when it is received.
If you do not agree with this decision, you have
the right to a second level appeal to the Plan
Administrator. Request for second level appeals
should be sent to:
Reimbursement Account Plan Administrator
Duke Benefits
705 Broad Street
Box 90502
Durham, NC 27708
The Plan Administrator will decide on your appeal
within 30 days of your second level appeal request.
If any of these claim deadlines falls on a Saturday,
Sunday, or holiday, the deadline is postponed until
the next business day. The Plan Administrator's
decision on your appeal is final and conclusive.
If you are dissatisfied with the Plan Administrator's
decision after you have pursued these steps, you
have the right to file a lawsuit in a state or federal
court. You may not file a lawsuit before 90 days
have passed after you file your claim or later than
three years after the event for which the claim was
made occurred.
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