Faculty & Staff
Risk & Benefits Management
Claim Appeals Process
An appeal may be made by an employee enrolled in this Plan when there is an alleged misinterpretation or misapplication of the specific benefits provided by this Plan that cannot be resolved satisfactorily through regular claim channels.
Questions and complaints regarding the initial settlement of an insurance claim should be directed verbally or in writing to the Claim Administrator (Mutual Medical Plans, Inc.).
After a claim has been denied by the Claim Administrator, an appeal may be sent to the Risk Management and Benefits Director at the College. The appeal must be submitted within the number of days specified, must be in writing and must be accompanied by copies of itemized bills and benefit explanation worksheets on which claims were denied. Reasons must be provided for why you feel the claim should be paid under applicable provisions of this Health Care Plan Description. A decision will be sent to you within 60 days after a full appeal is received.
A six-member Insurance Appeal Advisory Committee shall be designated to review complaints regarding claim denials and to recommend disposition of disputed claims.
Copies of the procedure and form for submitting appeals to the Committee are available in the Benefits Office.
The Plan Sponsor’s decision on an appeal shall be final and not subject to litigation.
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