Claims

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How to Submit a Claim. When a Covered Person has a claim to submit for payment, that person must:

  1. Obtain a claim form from the Human Resources Office or the Plan Administrator.
  2. Complete the Employee portion of the form. All questions must be answered.
  3. Have the Physician complete the provider’s portion of the form.
  4. For Plan reimbursements, attach bills for services rendered. All bills must show:
    • Name of Plan
    • Group number of Plan
    • Employee’s name
    • Name of patient
    • Name, address, telephone number of the provider of care
    • Diagnosis
    • Type of services rendered, with diagnosis and/or procedure codes
    • Date of services
  5. Charges Send the above to the Claims Administrator at this address:
      Pittman & Associates, Inc.
      P.O. Box 111047
      Memphis, TN 38111
      (901) 473-3100

When Claims Should Be Filed. Claims should be filed with the Claims Administrator within 90 days of the date charges for the service was incurred. Benefits are based on the Plan’s provisions at the time the charges were incurred. Charges are considered incurred when a treatment or care is given or a procedure performed. Claims filed later than that date may be declined or reduced unless:

  • it is not reasonably possible to submit the claim in that time; and
  • the claim is submitted within one year from the date incurred. This one-year period will not apply when the person is not legally capable of submitting the claim.

The Claims Administrator will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested from the claimant. The Plan reserves the right to have a Plan Participant seek a second medical opinion.

A request for Plan benefits will be considered a claim for Plan benefits, and it will be subject to a full and fair review. If a claim is wholly or partially denied, the Claims Administrator will furnish the Plan Participant with a written notice of this denial. This written notice will be provided within 90 days after receipt of the claim. The written notice will contain the following information:

  • the specific reason or reasons for the denial;
    specific reference to those Plan provisions on which the denial is based;
  • a description of any additional information or material necessary to correct the claim and an explanation of why such material or information is necessary; and
  • appropriate information as to the steps to be taken if a Plan Participant wishes to submit the claim for review.

A Plan Participant will be notified within 90 days of receipt of the claim as to the acceptance or denial of a claim and if not notified within 90 days, the claim shall be deemed denied.

If special circumstances require an extension of time for processing the claim, the Claims Administrator shall send written notice of the extension to the Plan Participant. The extension notice will indicate the special circumstances requiring the extension of time and the date by which the Plan expects to render the final decision on the claim. In no event will the extension exceed a period of 90 days from the end of the initial 90-day period.

Claims Review Procedure. In cases where a claim for benefits payment is denied in whole or in part, the Plan Participant may appeal the denial. This appeal provision will allow the Plan Participant to:

  1. Request from the Plan Administrator a review of any claim for benefits. Such request must include: the name of the Employee, his or her Social Security number, the name of the patient and the Group Identification Number, if any.
  2. File the request for review in writing, stating in clear and concise terms the reason or reasons for this disagreement with the handling of the claim.
    The request for review must be directed to the Plan Administrator or Claims Administrator within 60 days after the claim payment date or the date of the notification of denial of benefits.

A review of the denial will be made by the Plan Administrator and the Plan Administrator will provide the Plan Participant with a written response within 60 days of the date the Plan Administrator receives the Plan Participant’s written request for review and if not notified, the Plan Participant may deem the claim denied. If, because of extenuating circumstances, the Plan Administrator is unable to complete the review process within 60 days, the Plan Administrator shall notify the Plan Participant of the delay within the 60 day period and shall provide a final written response to the request for review within 120 days of the date the Plan Administrator received the Plan Participant’s written request for review.

The Plan Administrator’s written response to the Plan Participant shall cite the specific Plan provision(s) upon which the denial is based.

A Plan Participant must exhaust the claims appeal procedure before filing a suit for benefits.

 

Revised February 13, 2007.
Revised July 30, 2003.
Vice President for Finance and Business Affairs.

Note: The Rhodes College Handbook is not a contract of employment, nor should it be construed to create a contract with the College. Rhodes reserves the right to make future changes to its policies, practices, and fringe benefits. If such changes occur, the College will inform employees of such changes and their effect, if any. If you have questions, please contact The Rhodes Human Resources Department at hr@rhodes.edu.