Company health plan rules must explain how to get benefits and must include written procedures for processing claims. Complete plan rules are available from employers or benefits offices. There can be charges up to 25 cents a page for copies of plan rules.
Procedures for filing claims, approvals and denials must be described in the Summary Plan Description or SPD. Request this from your health plan administrator, especially if you are getting denial letters.
You should submit a claim for benefits in accordance with the plan's rules for filing claims. They may provide forms for you and/or to complete concerning the claim. If the claim is denied, you must be notified of the denial in writing usually within 90 days after the claim is filed. The notice should state the reasons for denial, additional information needed to support the reason for your claim being denied, and how to appeal the denial.
You should have at least 60 days to appeal a denial and you must receive a decision on the appeal usually 60 days after that.
Contact the plan administrator for more information on filing a claim for benefits. If you don't get the
required documentation, you might have to hire a lawyer, or complain to the DOL, or IRS.