Citi Benefits Handbook
Claims and Appeals for Express Scripts
The amount of time Express Scripts will take to make a decision on a claim will depend on the type of claim.
Type of claim
Timeline after claim is filed
Post-service claims (for claims filed after the service has been received)
  • Decision within 30 days; one 15-day extension due to matters beyond the control of the Claims Administrator (notice of the need for an extension must be given before the end of the 30-day period)
  • Notice that more information is needed must be given within 30 days
  • You have 45 days to submit any additional information needed to process the claim1
Preservice claims (for services requiring precertification of services)
  • Decision within 15 days; one 15-day extension (notice of the need for an extension must be given before the end of the 15-day period)
  • Notice that more information is needed must be given within five days
  • You have 45 days to submit any additional information needed to process the claim1
Urgent care claims (for services requiring precertification of services where delay could jeopardize life or health)
  • Decision made within 72 hours
  • Notice that more information is needed must be given within 24 hours
  • You have 48 hours to submit any additional information needed to process the claim; you will be notified of the decision within 48 hours of receipt of the additional information
1 Time period allowed to make a decision is suspended pending receipt of additional information.
If your claim is denied in whole or in part, you will receive a written explanation detailing:
  • The specific reasons for the denial;
  • Specific reference to the Plan documentation on which the denial is based;
  • A description of additional material or information you must provide to complete your claim and the reasons why that information is necessary;
  • The steps to be taken to submit your claim for review;
  • The procedure for further review of your claim; and
  • A statement explaining your right to bring a civil action under Section 502(a) of ERISA after exhaustion of the Program's appeals procedure.