Citi Benefits Handbook
Claims and Appeals for Oxford Health Plans Medical Plans
All claims for benefits must be filed within certain time limits. Medical claims must be filed within two years of the date of service. Claims are processed at the carrier in the order in which they are received from providers. Please note that this can differ from the order of the date of services. Claims cannot be reprocessed in the order of the dates of service due to Department of Labor timely filing rules.
In-Network Benefits
In general, if you receive covered services from an in-network provider, Oxford will pay the physician or facility directly. If an in-network provider bills you for any covered service other than your copay or coinsurance, please contact the provider or call the Customer Service phone number on your ID card for assistance.
Keep in mind, you are responsible for meeting the annual deductible and paying any copay or coinsurance owed to an in-network provider at the time of service, or when you receive a bill from the provider.
If you receive covered services from an in-network provider but not in accordance with the terms and conditions of the Plan/SPD, coverage will be provided as described in the Plan/SPD. When you see an in- network provider under these circumstances, the covered services will be treated as if they were delivered by an out-of-network provider, and you must file a claim as described below.
Out-of-Network Benefits
If you receive a bill for covered services from an out-of-network provider, you (or the provider if they prefer) must send the bill to Oxford for processing. To make sure the claim is processed promptly and accurately, a completed claim form must be attached and mailed to Oxford at the address on the back of your ID card.
How to Submit a Claim
You can obtain a claim form by visiting www.oxhp.com, calling the toll-free Customer Service number on your ID card or contacting your plan Administrator. If you do not have a claim form, simply attach a brief letter of explanation to the bill, and verify that the bill contains the information listed below. If any of these items are missing from the bill, you can include them in your letter:
  • Your name and address;
  • The patient's name, age and relationship to the participant;
  • The number as shown on your ID card;
  • The name, address and tax identification number of the provider of the service(s);
  • A diagnosis from the physician;
  • The date of service;
  • An itemized bill from the provider that includes:
    • the Current Procedural Terminology (CPT) codes;
    • a description of, and the charge for, each service;
    • the date the sickness or injury began; and
    • A statement indicating either that you are, or you are not, enrolled for coverage under any other health insurance plan or program. If you are enrolled for other coverage, you must include the name and address of the other carrier(s).
Failure to provide all the information listed above may delay any reimbursement that may be due you.
The above information should be filed with Oxford at the address on your ID card. When filing a claim for outpatient Prescription Drug Benefits, submit your claim to the pharmacy benefit manager claims address noted on your ID card.
Payment Options
When you receive covered services from an out-of-network provider, the plan will reimburse you and you will then be responsible for reimbursing the provider. You may not assign the right to reimbursement under the Plan/SPD to an out-of-network provider without Oxford's consent. However, in Oxford's discretion, the Plan may pay an out-of-network provider directly.
Limitations
All requests for reimbursement from participating providers must be made within 90 days of the date covered services were rendered. If coordination of benefits applies, the filing deadline is 120 days of the date on the explanation of benefits. Failure to request reimbursement within the required time will not invalidate or reduce any claim if it was not reasonably possible to provide such proof within the 90-day period. However, such request must be made as soon as reasonably possible thereafter. Under no circumstances will the plan be liable for a claim that is submitted more than six months after the date services were rendered, unless you are legally incapacitated and unable to submit the request. All reimbursements to out-of-network providers are subject to UCR unless you were referred to an in-network provider by your PCP or Oxford.
  • Participating providers: The filing deadline for claim submission is 90days from the date of service or date of discharge. If COB applies, the filing deadline is 120 days from the date on the EOB.
  • Members and non-participating providers: The filing deadline for claim submission is two years from the date of service.
If You Receive a Bill From an In-Network Provider
The cost of covered services provided by in-network providers in accordance with the terms of this Plan/SPD will be billed directly to Oxford. No claim forms are necessary.
If you should receive a bill from an in-network provider for covered services, please contact the Customer Service Department immediately.
Claim Information
Please allow up to 30 business days for the processing of in-network claims. Claims for out-of-network covered services will be paid within 60 business days after Oxford receives proof of the claim.
If necessary, Oxford's Claims Department will contact you for more information regarding your claim in order to speed up the processing. If you would like to inquire about the status of a claim, call the "Claims" telephone number list in the front of the Plan/SPD. Please have the date of service and your ID number ready.
Explanation of Benefits (EOB)
You may request that Oxford send you a paper copy of an Explanation of Benefits (EOB) after processing the claim. The EOB will let you know if there is any portion of the claim you need to pay. If any claims are denied in whole or in part, the EOB will include the reason for the denial or partial payment. If you would like paper copies of the EOBs, you may call the toll-free Customer Service number on your ID card to request them. You can also view and print all of your EOBs online at www.oxhp.com.
Limitation of Action
You cannot bring any legal action against the Plan Administrator or the Claims Administrator for any other reason unless you first complete all the steps in the appeal process described in this section. After completing that process, if you want to bring a legal action against the Plan Administrator or the Claims Administrator you must do so within three years of the date you are notified of the final decision on your appeal or you lose any rights to bring such an action against the Plan Administrator or the Claims Administrator.
Claim Denials and Appeals
If Your Claim Is Denied
If a claim for benefits is denied in part or in whole, you may call Oxford at the number on your ID card before requesting a formal appeal. If Oxford cannot resolve the issue to your satisfaction over the phone, you have the right to file a formal appeal as described below.
How to Appeal a Denied Claim
If you wish to appeal a denied pre-service request for benefits, post-service claim or a rescission of coverage as described below, you or your authorized representative must submit your appeal in writing within 180 days of receiving the adverse benefit determination. You do not need to submit Urgent Care appeals in writing. This communication should include:
  • The patient's name and ID number as shown on the ID card;
  • The provider's name;
  • The date of medical service;
  • The reason you disagree with the denial; and
  • Any documentation or other written information to support your request.
You or your authorized representative may send a written request for an appeal to:
Oxford — Appeals
P.O. Box 29139
Hot Springs, Arkansas 71903
For Urgent Care requests for benefits that have been denied, you or your provider can call Oxford at the toll-free number on your ID card to request an appeal.
Types of Claims
The timing of the claims appeal process is based on the type of claim you are appealing. If you wish to appeal a claim, it helps to understand whether it is an:
  • Urgent care request for benefits;
  • Pre-service request for benefits;
  • Post-service claims; or
  • Concurrent claim.
Review of an Appeal
Oxford will conduct a full and fair review of your appeal. The appeal may be reviewed by:
  • An appropriate individual(s) who did not make the initial benefit determination; and
  • A health care professional with appropriate expertise who was not consulted during the initial benefit determination process.
Once the review is complete, if Oxford upholds the denial, you will receive a written explanation of the reasons and facts relating to the denial.
Filing a Second Appeal
Your plan offers two levels of appeal. If you are not satisfied with the first level appeal decision, you have the right to request a second level appeal Oxford within 60 days from receipt of the first level appeal determination.
Note: Upon written request and free of charge, any covered member may examine documents relevant to their claim and/or appeals and submit opinions and comments. Oxford will review all claims in accordance with the rules established by the U.S. Department of Labor.
Federal External Review Program
If, after exhausting your internal appeals, you are not satisfied with the determination made by Oxford, or if Oxford fails to respond to your appeal in accordance with applicable regulations regarding timing, you may be entitled to request an external review of Oxford's determination. The process is available at no charge to you.
If one of the above conditions is met, you may request an external review of adverse benefit determinations based upon any of the following:
  • Clinical reasons;
  • The exclusions for Experimental or Investigational Services or Unproven Services;
  • Rescission of coverage (coverage that was cancelled or discontinued retroactively); or
  • As otherwise required by applicable law.
You or your representative may request a standard external review by sending a written request to the address set out in the determination letter. You or your representative may request an expedited external review, in urgent situations as detailed below, by calling the toll-free number on your ID card or by sending a written request to the address set out in the determination letter. A request must be made within four months after the date you received Oxford's decision.
An external review request should include all of the following:
  • A specific request for an external review;
  • The covered person's name, address, and insurance ID number;
  • Your designated representative's name and address, when applicable;
  • The service that was denied; and
  • Any new, relevant information that was not provided during the internal appeal.
An external review will be performed by an Independent Review Organization (IRO). Oxford has entered into agreements with three or more IROs that have agreed to perform such reviews. There are two types of external reviews available:
  • A standard external review; and
  • An expedited external review.
Standard External Review
A standard external review is comprised of all of the following:
  • A preliminary review by Oxford of the request;
  • A referral of the request by Oxford to the IRO; and
  • A decision by the IRO.
Within the applicable timeframe after receipt of the request, Oxford will complete a preliminary review to determine whether the individual for whom the request was submitted meets all of the following:
  • Is or was covered under the plan at the time the health care service or procedure that is at issue in the request was provided;
  • Has exhausted the applicable internal appeals process; and
  • Has provided all the information and forms required so that Oxford may process the request.
After Oxford completes the preliminary review, Oxford will issue a notification in writing to you. If the request is eligible for external review, Oxford will assign an IRO to conduct such review. Oxford will assign requests by either rotating claims assignments among the IROs or by using a random selection process.
The IRO will notify you in writing of the request's eligibility and acceptance for external review. You may submit in writing to the IRO within ten business days following the date of receipt of the notice additional information that the IRO will consider when conducting the external review. The IRO is not required to, but may, accept and consider additional information submitted by you after ten business days.
Oxford will provide to the assigned IRO the documents and information considered in making Oxford's determination. The documents include:
  • All relevant medical records;
  • All other documents relied upon by Oxford; and
  • All other information or evidence that you or your physician submitted. If there is any information or evidence you or your physician wants to submit that was not previously provided, you may include this information with your external review request and Oxford will include it with the documents forwarded to the IRO.
In reaching a decision, the IRO will review the claim anew and not be bound by any decisions or conclusions reached by Oxford. The IRO will provide written notice of its determination (the "Final External Review Decision") within 45 days after it receives the request for the external review (unless they request additional time and you agree). The IRO will deliver the notice of Final External Review Decision to you and Oxford, and it will include the clinical basis for the determination.
Upon receipt of a Final External Review Decision reversing Oxford determination, the plan will immediately provide coverage or payment for the benefit claim at issue in accordance with the terms and conditions of the Plan, and any applicable law regarding plan remedies. If the Final External Review Decision is that payment or referral will not be made, the plan will not be obligated to provide benefits for the health care service or procedure.
Expedited External Review
An expedited external review is similar to a standard external review. The most significant difference between the two is that the time periods for completing certain portions of the review process are much shorter, and in some instances you may file an expedited external review before completing the internal appeals process.
You may make a written or verbal request for an expedited external review if you receive either of the following:
  • An adverse benefit determination of a claim or appeal if the adverse benefit determination involves a medical condition for which the time frame for completion of an expedited internal appeal would seriously jeopardize the life or health of the individual or would jeopardize the individual's ability to regain maximum function and you have filed a request for an expedited internal appeal; or
  • A final appeal decision, if the determination involves a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the individual or would jeopardize the individual's ability to regain maximum function, or if the final appeal decision concerns an admission, availability of care, continued stay, or health care service, procedure or product for which the individual received emergency services, but has not been discharged from a facility.
Immediately upon receipt of the request, Oxford will determine whether the individual meets both of the following:
  • Is or was covered under the plan at the time the health care service or procedure that is at issue in the request was provided.
  • Has provided all the information and forms required so that Oxford may process the request.
After Oxford completes the review, Oxford will immediately send a notice in writing to you. Upon a determination that a request is eligible for expedited external review, Oxford will assign an IRO in the same manner Oxford utilizes to assign standard external reviews to IROs. Oxford will provide all necessary documents and information considered in making the adverse benefit determination or final adverse benefit determination to the assigned IRO electronically or by telephone or facsimile or any other available expeditious method. The IRO, to the extent the information or documents are available and the IRO considers them appropriate, must consider the same type of information and documents considered in a standard external review.
In reaching a decision, the IRO will review the claim anew and not be bound by any decisions or conclusions reached by Oxford. The IRO will provide notice of the final external review decision for an expedited external review as expeditiously as the claimant's medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request. If the initial notice is not in writing, within 48 hours after the date of providing the initial notice, the assigned IRO will provide written confirmation of the decision to you and to Oxford.
You may contact Oxford at the toll-free number on your ID card for more information regarding external review rights, or if making a verbal request for an expedited external review.
Timing of Appeals Determinations
Separate schedules apply to the timing of claims appeals, depending on the type of claim. There are three types of claims:
  • Urgent care request for benefits — a request for benefits provided in connection with urgent care services, as defined in Section 13, Glossary;
  • Pre-service request for benefits — a request for benefits which the plan must approve or in which you must call Oxford before non-urgent care is provided; and
  • Post-service — a claim for reimbursement of the cost of non-urgent care that has already been provided.
The tables below describe the time frames which you and Oxford are required to follow.
Urgent care request for benefits1
Type of request for benefits or appeal
Timing
If your request for benefits is incomplete, Oxford must notify you within:
24 hours
You must then provide completed request for benefits to Oxford within:
48 hours after receiving notice of additional information required
Oxford must notify you of the benefit determination within:
72 hours
If Oxford denies your request for benefits, you must appeal an adverse benefit determination no later than:
180 days after receiving the adverse benefit determination
Oxford must notify you of the appeal decision within:
72 hours after receiving the appeal
1 You do not need to submit urgent care appeals in writing. You should call Oxford as soon as possible to appeal an urgent care request for benefits.
Pre-service request for benefits
Type of request for benefits or appeal
Timing
If your request for benefits is filed improperly, Oxford must notify you within:
5 days
If your request for benefits is incomplete, Oxford must notify you within:
15 days
You must then provide completed request for benefits information to Oxford within:
45 days
Oxford must notify you of the benefit determination:
if the initial request for benefits is complete, within:
15 days
after receiving the completed request for benefits (if the initial request for benefits is incomplete), within:
15 days
You must appeal an adverse benefit determination no later than:
180 days after receiving the adverse benefit determination
Oxford must notify you of the first level appeal decision within:
15 days after receiving the first level appeal
You must appeal the first level appeal (file a second level appeal) within:
60 days after receiving the first level appeal decision
Oxford must notify you of the second level appeal decision within:
15 days after receiving the second level appeal
Post-service claims
Type of request for benefits or appeal
Timing
If your claim is incomplete, Oxford must notify you within:
30 days
You must then provide completed claim information to Oxford within:
45 days
Oxford must notify you of the benefit determination:
if the initial claim is complete, within:
30 days
after receiving the completed claim (if the initial claim is incomplete), within:
30 days
You must appeal an adverse benefit determination no later than:
180 days after receiving the adverse benefit determination
Oxford must notify you of the first level appeal decision within:
30 days after receiving the first level appeal
You must appeal the first level appeal (file a second level appeal) within:
60 days after receiving the first level appeal decision
Oxford must notify you of the second level appeal decision within:
30 days after receiving the second level appeal
Concurrent Care Claims
If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and your request to extend the treatment is an urgent care request for benefits as defined above, your request will be decided within 24 hours, provided your request is made at least 24 hours prior to the end of the approved treatment. Oxford will make a determination on your request for the extended treatment within 24 hours from receipt of your request.
If your request for extended treatment is not made at least 24 hours prior to the end of the approved treatment, the request will be treated as an urgent care request for benefits and decided according to the timeframes described above. If an on-going course of treatment was previously approved for a specific period of time or number of treatments, and you request to extend treatment in a non-urgent circumstance, your request will be considered a new request and decided according to post-service or pre-service timeframes, whichever applies.
Limitation of Action
You cannot bring any legal action against Citi or the Claims Administrator to recover reimbursement until 90 days after you have properly submitted a request for reimbursement as described in this section and all required reviews of your claim have been completed. If you want to bring a legal action against Citi or the Claims Administrator, you must do so within three years from the expiration of the time period in which a request for reimbursement must be submitted or you lose any rights to bring such an action against Citi or the Claims Administrator.
You cannot bring any legal action against Citi or the Claims Administrator for any other reason unless you first complete all the steps in the appeal process described in this section. After completing that process, if you want to bring a legal action against Citi or the Claims Administrator you must do so within three years of the date you are notified of the final decision on your appeal or you lose any rights to bring such an action against Citi or the Claims Administrator.