Post Service Claims
All claims outside of urgent, pre-service and disability, for benefits under the group health plan, including claims after medical services have been provided, such as requests for reimbursement or payment of the costs of the services provided. Most claims for group health benefits are post service claims.
- These types of claims must be decided within a reasonable period of time, but not later than 30 days after the plan has received the claim. If for reasons beyond the control of the plan, more time is needed to review the members request the plan may extend the time up to 15 days more. However, the plan administrator has to let the member know before the end of the 30 days. They must also tell the member the reason for the delay request, any additional information needed, and advise the member when a final decision should be expected.
- If more information is needed then the member has at least 45 days to supply it. The claim then must be decided no later than 15 days after the member supplies the additional information or the period of time given by the plan to do so end, whichever comes first. The plan needs the member’s consent if it needs more time after the first extension. The plan must give the member notice that the claim has been denied in whole or in part before the end of the allotted time for the decision.
This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.