Citi Benefits Handbook
Claims and Appeals for the Health Care Spending Account (HCSA)/Limited Purpose Health Care Spending Account (LPSA)
A HCSA/LPSA claim must be filed by June 30th of the Plan year following the year in which the claim was incurred (2017 plan year claims must be submitted and resolved by June 30, 2018). To submit a claim, you must complete a claim form authorized by the Plans Administration Committee of Citigroup Inc. (the "Committee"), the Plan Administrator. To obtain a copy of the claims form, contact the Citi Benefits Center through ConnectOne at 1 (800) 881-3938.
If a HCSA/LPSA benefit is denied, in whole or in part, under the Employee Retirement Income Security Act of 1974, as amended, ("ERISA") you are entitled to appeal the denial of your claim by following the steps below.
Step 1: You will receive written notice from the Citi Benefits Center if your claim is denied as soon as reasonably possible, but no later than 30 days after receipt of the claim. However, for reasons beyond the control of the Citi Benefits Center, it may take up to an additional 15 days to review your claim. You will be provided written notice of the need for additional time prior to the end of the initial 30-day period, if applicable. If the reason for the additional time is that you need to provide additional information, you will receive written notice of the requested information and you will have 45 days from the notice of the extension to provide that information to the Citi Benefits Center. The time period during which the Citi Benefits Center must make a decision will be suspended until the earlier of the date that you provide the information or the end of the 45-day period. If the requested information is not received within the 45 day period noted, a determination with respect to your claim will be made without the requested information.
Step 2: Once you have received your notice from the Citi Benefits Center, review it carefully. The notice will contain the following information:
  • The reason(s) for the denial and the Plan provisions on which the denial is based;
  • A description of any additional information necessary for you to perfect your claim, why the information is necessary, and your time limit for submitting the information;
  • A description of the Plan's appeal procedures and the time limits applicable to such procedures;
  • A statement explaining your rights to bring civil action under Section 502(a) of ERISA after an adverse benefit determination upon review;
  • If an internal rule or guideline was relied on in making the adverse determination, either the specific rule or guideline, or a statement that such a rule or guideline was relied on in making the adverse determination and that a copy of such rule or guideline will be provided free of charge on request; and
  • If the adverse determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request.
Step 3: If you disagree with the determination with respect to your claim, contact the Citi Benefits Center through ConnectOne at 1 (800) 881-3938 for assistance. If you are still unable to resolve your issue and have your claim approved, you may file an appeal. You may obtain an appeal form from the Citi Benefit Center spending account team by contacting them through ConnectOne at 1 (800) 881-3938. You should file your appeal no later than 180 days after receipt of the notice described in Step 1. Complete and return the appeal form along with any additional supporting documentation with respect to why you believe your claim should be approved, along with all the information identified in the notice of denial as necessary to perfect your claim and any additional information that you believe would support your claim to the address or fax number noted below for a determination on your appeal.
Citigroup Inc.
Plans Administration Committee of Citigroup Inc.
c/o Claims and Appeal Management Team
P.O. Box 1407
Lincolnshire, IL 60069-1407
Fax: 1 (847) 554-1653
Step 4: The Committee or a designee of the Committee will conduct a full and fair review of your appeal. You and/or your representative may review the Plan documents and submit written comments or a statement with your appeal. A determination with respect to the appeal of your denied HCSA/LPSA claim shall be reached within a reasonable period of time, but no later than 60 days after the receipt of appeal. If the HCSA/LPSA claim is denied, you will be notified in writing of the benefit determination upon review. The notice will be sent no later than 60 days after receipt of the appeal by the Citi Benefits Center.
Step 5: Once you have received your notice of the benefit denial upon appeal from the Citi Benefits Center, review it carefully. The notice will contain the following information:
  • The reason(s) for the denial and the Plan provisions on which the denial is based;
  • A statement that you are entitled to receive, upon request and free of charge, or have reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits;
  • A statement explaining your rights to bring civil action under Section 502(a) of ERISA;
  • If an internal rule or guideline was relied on in making the adverse determination, either the specific rule or guideline, or a statement that such a rule or guideline was relied on in making the adverse determination and that a copy of such rule or guideline will be provided free of charge on request;
  • If the adverse determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request; and
  • You and the HCSA/LPSA may have other voluntary alternate dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office or your State insurance regulatory agency.