Claims & Appeals

How to file a claim

Log in to your member portal and select “submit a claim.” Fill out the online form and attach your supporting documentation. Itemize all your expenses.

You may also print and fill out the appropriate claim form, itemize your expenses, sign and date the form, and then mail it to us.

With either type of form, all expenses must include the following supporting documentation:

1. Date of Service
2. Type of Service performed
3. Provider's Name
4. Amount of Charges
5. For Prescription expenses, the Rx # or name of prescription must be included with all of the above.
6. For Dependent Care expenses, the provider's Tax ID or Social Security number must be included with all of the above.

Acceptable types of Supporting Documentation Include:

1. Itemized billing statement from provider with dates of service and types of service performed.
2. Explanation of Benefit from your insurance company
3. Receipt from provider with all information above.

Unacceptable (per the IRS) types of Supporting Documentation include:

1. Canceled checks or copies of checks
2. Credit card receipts or billing statements
3. Balance forward or previous balance statements
4. Estimates of services to be incurred.

• Dates of services must take place during your Plan Year. Eligible expenses will be reimbursed based on the date the service was incurred, not the date when the service was billed or paid for.
• Expenses incurred prior to your effective date, or after termination in the plan are not eligible for reimbursement.
• You will likely have a runout period after the end of the Plan Year to request reimbursement of services incurred during the Plan Year. Please contact your employer to determine the runout period for your group ’s plan year. Any claim not postmarked or otherwise not received by the last day of the runout will be denied. The appeal process is not a remedy for late claims.
• Your claim will be processed within 3-5 business days, and a check or direct deposit statement will be mailed to your home. All reimbursements will be issued to the member. We cannot issue checks to providers.

How to make an appeal

If you feel an adverse decision regarding your COBRA coverage or FSA claim has been made by BenefitHelp Solutions, you (or your authorized representative) have the right to appeal the decision.

First Level Written Appeal

For your convenience, please complete and send us the COBRA appeal form or the FSA appeal form.

Second Level Written Appeal

If you disagree with the decision made by the first level appeal process, you are provided 60 days to file another written appeal for reconsideration. The BHS Appeals Committee will review all elements of your situation to ensure your appeal has been handled properly. A decision will be made within 30 days of the receipt of your additional written request. A letter will be provided regarding the outcome of the BHS Appeals Committee decision within 30 days of the receipt of your additional written request. If you disagree with the decision made in the second level appeal, you have the right to file an action with the appropriate court challenging the decision.

More about the appeal review process

Your appeal will be reviewed by a person who was not involved with the initial determination. The review will be a fresh look at your appeal and take into account all information submitted. For more information about appeal rights, click here (expand to include info below):

Appeals Procedure

Procedure If Benefits Are Denied Under This Plan

If a claim for reimbursement or benefit under this Plan is wholly or partially denied, such claim shall be administered in accordance with the procedure set forth below and in the summary plan documents of this Plan. The Appeals Committee, separate and distinct from the individual(s) that adjudicate the claims, shall act on behalf of the Plan Administrator with respect to appeals. An external review process shall be provided as legally required and as further set forth below.

Claims. If (a) a claim for reimbursement is wholly or partially denied, or (b) Participant is denied a benefit under the Plan due to an issue germane to said coverage under the Plan, then the procedure described below will apply.

If a claim is denied in whole or in part, Participant will be notified in writing by BenefitHelp Solutions within 30 days after the date BenefitHelp Solutions received the claim. (This time period may be extended for an additional 15 days for matters beyond the control of BenefitHelp Solutions including in cases where a claim is incomplete. BenefitHelp Solutions will provide written notice of any extension, including the reasons for the extension and the date by which a decision by the Plan Administrator is expected to be made.)

Notification of a denied claim will include:

• A statement of the specific reason(s) for the denial
• Reference(s) to the specific Plan provision(s) on which the denial is based
• A description of any additional material or information necessary for Participant to validate the claim and an explanation of why such material or information is necessary
• Appropriate information on the steps to be taken if Participant wishes to appeal the Plan Administrator's decision, including their right to submit written comments and have them considered, their right to review (upon request and at no charge) relevant documents and other information, and their right to file suit under ERISA (where applicable) with respect to any adverse determination after appeal of their claim.

Appeals. If a claim is denied in whole or in part, then the Participant (or authorized representative) may request review upon written application to BenefitHelp Solutions Compliance Analyst. The appeal must be made in writing within 180 days after Participant's receipt of the notice that the claim was denied. If Participant does not appeal on time, Participant will lose the right to appeal the denial and the right to file suit in court. Participant's written appeal should state the reasons that they feel their claim should not have been denied. It should include any additional facts and/or documents that they feel support their claim. Participant will have the opportunity to ask additional questions and make written comments, and Participant may review (upon request and at no charge) documents and other information relevant to their appeal.

Participant will not be allowed to take legal action against the Plan, «Employer», the Administrator, or any other entity to whom administrative or claims processing functions have been delegated unless they exhaust the internal appeal rights. A Participant does not have to pursue external review in order to preserve the right to file a lawsuit; however, a Participant may be unable to take further legal action if they pursue an external appeal because the external appeal process results in a binding determination.

Decision on Review of Internal Appeal. Participant's internal appeal will be reviewed and decided by BenefitHelp Solutions Compliance Analyst within a reasonable time not later than 60 days after BenefitHelp Solutions Compliance Analyst receives Participant's request for review. BenefitHelp Solutions Compliance Analyst may, in its discretion, hold a hearing on the denied claim. Any medical expert consulted in connection with their internal appeal will be different from and not subordinate to any expert consulted in connection with the initial claim denial. The identity of a medical expert consulted in connection with the internal appeal will be provided. If the decision on review affirms the initial denial of the claim, Participant will be furnished with a notice of adverse benefit determination on review setting forth:

• a statement of the specific reason(s) for the decision on review;
• reference(s) to the specific Plan provision(s) on which the decision is based;
• a statement of Participant's right to review (upon request and at no charge) relevant documents and other information;
• if an "internal rule, guideline, protocol, or other similar criterion" is relied on in making the decision on review, then a description of the specific rule, guideline, protocol, or other similar criterion or a statement that such a rule, guideline, protocol, or other similar criterion was relied on and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to Participant upon request; and
• A statement of Participant's right to bring an external appeal or a civil action under ERISA Section 502(a) (where applicable).

Decision on Second Review of Internal Appeal. If Participant disagrees with the decision to uphold the denial, a second level appeal will be reviewed and decided by the Appeals Committee within a reasonable time not later than 30 days after the Appeals Committee receives Participant's request for review. The Appeals Committee may, in its discretion, hold a hearing on the denied claim. Any medical expert consulted in connection with their internal appeal will be different from and not subordinate to any expert consulted in connection with the initial claim denial. Participant may have the right to an external review of the Administrator's denial of the internal appeal of the claim unless the Benefit denial was based on the Participant's (or their Spouse's or Dependent's) failure to meet the Plan's eligibility requirements.

Requirements for an External Appeal. Participant may request an external appeal by completing the form provided by the Administrator which must include the following information:

• Participant's name, address, daytime telephone number and email address; and
• A brief description of why the Participant disagrees with the decision, along with any additional information, such as a physician's letter, bills, medical records, or other documents to support their claim.

Deadline for filing an External Appeal. Participant's external appeal must be filed with the external reviewer within four (4) months of the date the Participant was served with the Administrator's response to their internal appeal request. If Participant does not file an external appeal within this 4-month period, the Participant shall lose the right to appeal. For example, if Participant received the internal appeal decision on January 3, 2012, they must appeal the decision by May 3, 2012 (or, if that is not a business day, the next business day thereafter). The plan must complete a preliminary review within five (5) business days upon receipt of the external review request to determine if the claimant was covered under the plan, the claimant provided all of the necessary information to process the external review and that the claimant has exhausted the internal appeals process. The plan must provide the claimant written notice of its preliminary review determination within one (1) business day after completing its review. If the request is complete, but not eligible for external review, the notice must state the reasons for the ineligibility and provide EBSA contact information. If the request is incomplete, the notice must describe the information or materials needed to complete the request. The plan must permit the claimant to "perfect" (i.e., complete) the external review request within the four-month filing period or, if later, 48 hours after receipt of the notice.

Decision on Review of External Appeal. The plan must assign an accredited Independent Review Organization (IRO) to perform the external review. The external reviewer must notify you and the Administrator of its decision on your external appeal within 45 days after its receipt of your request for external review. The external reviewer's decision is binding upon the parties unless other State or Federal law remedies are available. Such remedies may or may not exist. Therefore, unless another legal right exists under your claim, use of the external review process may terminate your right to bring a lawsuit on your claim.

Duty of Beneficiary/Third Party Recoveries. Any Beneficiary under the Plan that receives a payment, whether by lawsuit, settlement, or otherwise, from third parties for costs associated with sickness or injury resulting from the acts or omissions of another person or party must reimburse the Plan to the extent the Beneficiary has received payments from the Plan for such sickness or injury. The Plan has a first lien upon any such recovery. Any recovery by the Plan Administrator from such payments is subject to a deduction for reasonable attorney fees and court costs incurred by the Beneficiaries in securing the third-party payments, and shall be prorated, to reflect that portion of the total recovery reimbursed to the Plan Administrator for the benefits it had paid from the Plan. However, the Plan's share of the recovery will not be reduced because the Beneficiary has not received the full damages claimed, unless the Plan Administrator agrees in writing to such a reduction.

The Plan further requires covered Beneficiaries promptly advise the Plan Administrator of third-party claims and to execute any assignments, liens, or other documents the Plan Administrator requests. The Plan may withhold Benefits until such documents are received.

Subrogation/Acts of Third Parties. The Plan Administrator, on behalf of the Plan, has the right to recover any payments made to Beneficiaries, whether by lawsuit, settlement, or otherwise, by third parties for costs associated with sickness or injury resulting from the acts or omissions of another person or party. The Plan has a first lien upon any such recovery. Any recovery by the Plan Administrator from such payments is subject to a deduction for reasonable attorney fees and court costs incurred by the Beneficiaries in securing the third-party payments, and shall be prorated, to reflect that portion of the total recovery reimbursed to the Plan Administrator for the benefits it had paid from the Plan. However, the Plan's share of the recovery will not be reduced because the Beneficiary has not received the full damages claimed, unless the Plan Administrator agrees in writing to such a reduction.