Benefit Appeal Process

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:

  1. The benefit plan should notify you within 90 days of receipt of a claim that your claim has been wholly or partially denied.
  2. 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.
  3. 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.
  4. 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.
  5. 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.