Claim denied: Now what?

If you file a claim and it is denied, you’ll need to provide proof that the product or service was for a medically necessary reason. Please see below for the next steps based on the claim type.

Manual/online claim:

1. Within 10 days of receiving the denial letter, submit documentation showing provider’s name, service date, service type, and dollar amount – along with the *Medical Necessity Form, if applicable. Once documents are received and approved, your claim will be processed and paid. Medical forms are located on the member website: “Tools & Support” > “Account Support & Forms.”
   

   *A Medical Necessity Form is only needed if the service provided isn’t typically covered by the plan (for example, massages are not normally covered, however if the service was deemed and documented medically necessary to heal a chronic condition, by a doctor – then the service may be covered and claim approved).

2. If you do not return the required documentation within 10 days, your claim will go into an Overdue status. And if the additional documents aren’t received by day 30 – your claim will be denied.

Debit card claim:

1. Within 10 days of receiving the denial letter, submit documentation showing provider’s name, service date, service type, and dollar amount – along with the *Medical Necessity Form, if applicable. Once documents are received and approved, your claim will be processed and paid. Medical forms are located on the member website: “Tools & Support” > “Account Support & Forms.”
   

   *A Medical Necessity Form is only needed if the service provided isn’t typically covered by the plan (for example, massages are not normally covered, however if the service was deemed and documented medically necessary to heal a chronic condition, by a doctor – then the service may be covered and claim approved).

2. If you do not return the required documents within 10 days, you’ll receive a Final Debit Card Receipt Request, and you will have an additional 10 days to submit documents. If your documents are not received within the stated time frame, your debit card will be suspended and you will received a denial letter along with a request for repayment. When your debit card is suspended, the card suspension will last until the claim is repaid.
3. Once documents are received and approved, your claim status will be updated to Approved and the debit card will be unsuspended.

Your substantiation is denied

If you receive a denial letter or ineligible notice, you can resubmit your claim for review if you have updated documentation for the expense. If you need to appeal a claim decision, you’ll need to call the Customer Care Center for next steps.