Chart of Time Limits in Appealing a Claim
The following time limits apply for the Claim Administrator to respond after you file a claim with the appropriate
Claim Administrator.
| CLAIM ADMINISTRATORS |
CIGNA HEALTHCARE FOR MEDICAL AND BEHAVIORAL HEALTH CLAIMS, CVS CAREMARK FOR PRESCRIPTION DRUG CLAIMS, AETNA FOR DENTAL CLAIMS AND FAA/EYEMED FOR VISION CLAIMS |
|
Urgency of Appeal
|
Urgent Care
|
Non-Urgent Care Pre-Service Claims
|
Non-Urgent Care Post Service Claims
|
|
|
For initial benefit determination
|
72 hours
|
15 days
|
30 days
|
|
|
To extend initial benefit determination
|
None
|
15 days
|
15 days
|
|
|
To notify claimant of improperly filed or incomplete claim
|
24 hours
|
5 days
|
30 days
|
|
|
For claimant to supply missing information
|
48 hours minimum
|
45 days
|
45 days
|
|
|
For claimant to appeal initial adverse benefit determination
|
180 days
|
180 days
|
180 days
|
|
|
For Plan to make a determination on appeal
|
45 days
|
30 days (15 days if the Plan has two appeals)
|
60 days (30 days if the Plan has two appeals)
|
|
|
For Plan to extend determination of appeal
|
45 days
|
None
|
None
|
|
This is a summary of the time limits that apply. Please read the description which follows carefully to properly
understand your rights when you file a claim and when you wish to formally appeal the denial of a claim. Please
note that if a claim has been denied and you wish to better understand the reasons for the denial, you may call the
Claim Administrator to discuss the denial without changing your rights to appeal. Also, note that vision claims will all be governed by the “Non-Urgent Care Post-Service Claims” time limits because of the way in which the Plan operates.
A request for prior approval of a benefit that does not require prior approval by the Plan is not a claim for
benefits. In addition, when you present a prescription to a pharmacy to be filled under the terms of this Plan, that
request is not a claim under these procedures. However, if your request for a prescription is denied, in whole or in
part, you may file a claim and appeal the denial by using these procedures.
A claim form may be obtained from the administrator responsible for processing the claim (the Claim Administrator),
from the MILA Fund Office or from your local Port administrator. Claim forms are also available on
MILA’s website.
