How to File a Claim

Filing a Claim

You must file a claim within 12 months of the date the service was provided. Any claims filed after 12 months will not be covered.

Please note: For purposes of the Plan’s claims and appeals procedures, a claim does not include the following: (i) casual inquiries about benefits or the circumstances under which benefits might be paid under the terms of the Plan; or (ii) mere requests for advance information on the Plan’s possible coverage of items or services. A determination of eligibility under the Plan (including a request or application for such determination) will not be treated as a claim under the Plan and will be determined by the Plan Administrator in accordance with a procedure established by the Plan Administrator. However, if an individual files a request for benefits in accordance with the Plan’s procedure for filing claims, and that claim is denied because the individual is not eligible for coverage under the Plan, the coverage determination will be considered to be part of a claim.

Benefit Determinations

Once the claims administrator receives a properly filed claim from you or your provider, a benefit determination will be made within 30 days. This period may be extended one time for up to 15 additional days, if the claims administrator determines that additional time is necessary.

If the claims administrator determines that additional time is necessary, you will be notified, in writing, prior to the expiration of the original 30-day period, that the extension is necessary, along with an explanation of the circumstances requiring the extension of time and the date by which the claims administrator expects to make the determination.

Upon receipt of your claim, if the claims administrator determines that additional information is necessary in order for it to be a properly filed claim, the claims administrator will provide you with written notice of the specific information needed prior to the expiration of the initial 30-day period. You will have 45 days from receipt of the notice to provide the additional information. The claims administrator will notify you of its benefit determination within 15 days following receipt of the additional information.

If a claim for benefits is denied, in whole or in part, you or your beneficiary(s) will receive written notice of the decision. The written notice will include the following:

  • The specific reason(s) for the denial or decision
  • Specific reference to the Plan provision(s) on which the denial or decision was based
  • A description of any additional material or information necessary to perfect the claim and an explanation of why it is necessary
  • An explanation of the claim review procedure including a statement that you may bring a civil action under section 502(a) of ERISA only after a benefit denial on review of your appeal
  • If an internal rule, guideline or protocol, or other similar criterion ("criterion") was relied upon in making the denial, either the:

    • Specific criterion used, or
    • A statement that such criterion was relied upon in making the benefit denial and that a copy of such criterion will be provided free of charge upon request.

  • If the benefit denial is based on medical necessity or experimental treatment limitation, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the person's special medical circumstances, or a statement that such explanation will be provided free of charge upon request.

Claim Appeals Procedure

The Vision Plan has established the following process to review any dissatisfactions, complaints, and appeals. If you have designated an authorized representative, that person may act on your behalf in the appeal process. Please note: designation of an authorized representative does not constitute a waiver of the Health Care Program's anti-assignment provisions.