General Description of the Benefits Appeal Process
The following procedures are suggested for any employee, retiree or their dependents who are filing an appeal for a health benefits claim that has been wholly or partially denied by a benefit plan. The step-by-step process should be:
- The benefit plan should notify you within 90 days of receipt of a claim that your claim has been wholly or partially denied.
- The benefit plan should notify you at the same time of denial, the steps needed to be followed by you to file an appeal to the benefit plan.
- When all levels of appeal to the benefit plan have been exhausted, you have the right to request a review, in writing, by the State Employee Benefits Division of the Department of Budget and Management within 90 days.
- If you do not receive a favorable response to your appeal from the State Employee Benefits Division, you may request additional review within 60 days by the Benefits Review Committee which is made up of high-level staff from different agencies. The decision of the Benefits Review Committee shall be final.
- At each step in the appeal process, the decision shall include specific reasons for the decision(s) and any plan provisions on which the decision is based.