Citi Benefits Handbook
Claims and Appeals for CVS Caremark
The amount of time CVS Caremark 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.
Important COVID-19-Related Changes that Extend Claims and Appeals Deadlines
On May 4, 2020, the U.S. Departments of Labor and the Treasury (the Agencies) issue guidance that temporarily extends the deadlines in place for certain benefit changes and processes associated with election, notification, payment and claims/appeals in connection with the Coronavirus disease of 2019, which was deemed a national emergency on March 1, 2020 (the National Emergency). To protect individuals from losing benefit, the Agencies extended deadlines that might have been missed during the National Emergency. The temporary extension of the deadlines was initially set to expire 60 days after the end of the National Emergency. The Agencies have revised their guidance to provide that your extended deadline will end on the earlier of one year from your original deadline or your original time limit after the end of the National Emergency as described above (Agencies' deadline).
If your deadline to file a claim or appeal falls within the Agencies' deadline, you will have additional time to submit your claim.
For more information, contact the Claims Administrators as detailed under "Claims Administrators" in the Administrative Information section, or call the Citi Benefits Center via ConnectOne at 1 (800) 881-3938 for additional help. From the Benefits menu, select the appropriate option. See the For More Information section for detailed instructions, including TDD and international assistance.
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.