Citi Benefits Handbook
Claims and Appeals
Claims must be submitted in order to receive reimbursement for charges you incur when you seek care under the Plans. Many times, claims are submitted electronically to the Claims Administrator without your intervention needed. However, you may be required to manually submit claims for expenses to be paid or approved for reimbursement. For example, if you see an out-of-network physician, you will be required to manually submit a claim. Listed below are the forms needed to claim benefits that may not be reimbursed automatically or paid directly. Claims should be sent to the Claims Administrators as detailed under "Claims Administrators."
To file an eligibility or enrollment-related claim or appeal, for example, if enrollment in Citi Health and Insurance benefits has been denied in whole or in part, see "Eligibility and Enrollment Claims".
All claims for benefits must be filed within certain time limits for reimbursement.
  • Medical, dental, and vision claims must be filed within two years of the date of service.
  • Prescription drug claims must be filed within one year of the date of service.
  • HCSA/LPSA/DCSA claims must be filed and resolved (i.e. all substantiating documentation must be submitted) by June 30 of the calendar year following the Plan year in which the expense was incurred.
  • TRIP parking cash reimbursement option claims must be filed within 12 months from the date of service.
How to file a claim
Medical
  • For the ChoicePlan 500, Oxford PPO and High Deductible Health Plan (HDHP) (non-HMOs)
Use one of the following forms, available in the Forms and Claims section of Citi Benefits Online at www.citibenefitsonline.com, to file a claim for a covered out-of-network expense:
  • Aetna claim form (for ChoicePlan 500 and HDHP participants)
  • Anthem BlueCross BlueShield claim form (for ChoicePlan 500 and HDHP participants)
  • Oxford Health Plan claim form
  • HMO participants
  • Call your HMO for any claim-filing information.
Prescription Drugs
  • Express Scripts (prescription drug program related to all non-HMO medical plans including the ChoicePlan 500, HDHP, and Oxford Health Plan)
Use the Express Scripts Prescription Drug Claim form, available in the Forms and Claims section of Citi Benefits Online at www.citibenefitsonline.com, to file a claim for a covered out-of-network expense.
To access home delivery order forms, log in to www.express-scripts.com and click on "Forms and Cards."
Dental
  • MetLife Preferred Dentist Program (PDP)
  • Cigna Dental Care DHMO
  • There are no claim forms to file under this Plan.
Vision
  • Aetna Vision
  • Aetna Vision Plan claim form, available in the Forms and Claims section of Citi Benefits Online at www.citibenefitsonline.com.
  • Call the Aetna Vision Plan at 1 (877) 787-5354.
Be Well Program
 
Health Care Spending Account (HCSA) and Limited Purpose Health Care Spending Account (LPSA)
 
  • If you do not use your debit card for eligible HCSA or LPSA expenses, you can file a claim by using the Health Care Spending Account/Limited Purpose Health Care Spending Account claim form. If a receipt is needed, you will be notified within 30 days. Claim forms are available in the Forms and Claims section of Citi Benefits Online at www.citibenefitsonline.com, or submit a claim online via the CYC website. You can access CYC through TotalComp@Citi at www.totalcomponline.com, available from the Citi intranet and the Internet.
Dependent Day Care Spending Account (DCSA)
 
Transportation Reimbursement Incentive Program (TRIP)
  • For TRIP parking participants enrolled in the Cash Reimbursement Option only
  • To file a claim, the Transportation Reimbursement Incentive Program (TRIP) claim form is available on the ConnectYourCare (CYC) website through TotalComp@Citi at www.totalcomponline.com. From the main page, click on "Want to get somewhere fast" and then select the "Spending Accounts/Health Savings Account" option that appears under "Other Websites.".
Short-Term Disability (STD)
 
  • To file a claim, call MetLife, the Claims Administrator for the STD Plan, at 1 (888) 830-7380 ; for text telephone service, call 1 (877) 503-0327. You can also call ConnectOne at 1 (800) 881-3938. See the For More Information section for detailed instructions, including TDD and international assistance.
Basic Life and Basic AD&D insurance
 
  • To file a claim, your beneficiary may call the Citi Benefits Center through ConnectOne at 1 (800) 881-3938. See the For More Information section for detailed instructions, including TDD and international assistance.
GUL and Supplemental AD&D insurance
 
  • To file a claim, your beneficiary may call the Citi Benefits Center through ConnectOne at 1 (800) 881-3938. See the For More Information section for detailed instructions, including TDD and international assistance.
To file a claim or appeal, you must use the designated form in accordance with the applicable Citigroup Health and Welfare Plan procedures. By participating in the Citigroup Health and Welfare Plans, you and your beneficiaries agree that you cannot commence a legal action against any of the Citigroup Health and Welfare Plans more than one year after your final appeal has been denied, unless an insurance contract made available under the Plan provides for a different limitation. No legal action can be brought to recover benefits under any of the Plans until the appeal rights described below have been exercised, and the Plan benefits requested in such appeal have been denied.
If you do not receive a benefit to which you believe you are entitled under any Citigroup Health and Welfare Plans subject to ERISA, which excludes HSA, DCSA and TRIP, or if your application for benefits is denied, in whole or in part, you may file a claim with the Plan Administrator or Claims Administrators, as applicable. For more information about the Plan Administrator and Claims Administrators, see "Plan Administration" and the list of Claims Administrators under "Claims Administrators."
Please note that the health savings account ("HSA") associated with the HDHP benefit options is an account owned by each participant who establishes an HSA. The Citi HSA is not a plan and is designed to be exempt from ERISA.
The Plan Administrator or Claims Administrator is generally required to evaluate your claim and notify you of its decision within a specified time period in accordance with ERISA. If your written claim is denied, you have a right to appeal the claim denied by the Plan Administrator or Claims Administrator by filing a request for review of your claim denial. If you wish to bring legal action against the Company or the one of the Citigroup Health and Welfare Plans, you must first go through the Citigroup Health and Welfare Plan's appeals procedures.
ERISA provides for different timetables and claims procedures that may vary by type of benefit. Each of the medical benefits (including dental and vision benefits), disability benefits, and all other types of benefits has a different timetable and claims and appeals procedures. General information about the claims and appeals procedures is set forth below.
Detailed procedures governing claims for benefits, applicable time limits, and remedies available under the Citigroup Health Benefit Plan, the Citigroup Dental Benefit Plan, the Citigroup Vision Benefit Plan, the Health Care Spending Accounts (HCSA/LPSA) and the Citigroup Disability Plan for the redress of denied claims are included in this Handbook.