This is a brief summary of the claims appeal process. Full details are available in the Plan Document in Article 12, especially Sections 12.7 through 12.12.
Refer to Article 12, Section 12.5 of the Plan Document for specific information as to the timeframe for an initial benefit determination to be made. If you or your health provider have sent in a “Post-Service” claim and have not received any response within 30 days, first please contact North American Administrators to make sure the claim was received. If the claim has not been received, arrange for it to be resubmitted for processing.
If your claim has been denied or you do not believe the benefit has been calculated correctly, first contact North American Administrators to review with them the information they received regarding the claim. It is possible the information provided is not correct or complete and the matter can be cleared up by you or your provider providing correct or more complete information.
If the information is correct and complete and the claim is still denied or the benefit which has been determined is still not what you believe it should be, you may appeal the claim by submitting all information you feel to be useful and to the point to the Executive Director for consideration by the Board of Directors. Be sure to provide all information in writing to include at least: employee name and social security number, patient name, claim number, date of service, provider name and the reason or reasons you believe the claim has been incorrectly denied or calculated.
Once you have submitted your appeal to the Executive Director you may be contacted for additional information. The role of the Consortium Staff is to attempt to ensure that all useful information is presented to the Board for each appeal being considered. All properly received appeals are presented to the Board by the Executive Director within the timeframes described in Section 12.10 of the Plan Document, after all identifying information has been removed to ensure their unbiased consideration. Once the Board has reached a decision you will be notified of that decision in writing.