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Claims

How to Submit a Claim. When a Covered Person has a claim to submit for payment, that person must:

  1. Obtain a claim form from the Human Resources Office or the Plan Administrator.
  2. Complete the Employee portion of the form. All questions must be answered.
  3. Have the Physician complete the provider’s portion of the form.
  4. For Plan reimbursements, attach bills for services rendered. All bills must show:
    • Name of Plan
    • Group number of Plan
    • Employee’s name
    • Name of patient
    • Name, address, telephone number of the provider of care
    • Diagnosis
    • Type of services rendered, with diagnosis and/or procedure codes
    • Date of services
  5.  Send the above to the Claims Administrator at this address:
    HealthSmart
    P.O. Box 111047
    Memphis, TN 38111
    (901) 473-3100

When Claims Should Be Filed. Claims should be filed with the Claims Administrator within 90 days of the date charges for the service was incurred. Benefits are based on the Plan’s provisions at the time the charges were incurred. Charges are considered incurred when a treatment or care is given or a procedure performed. Claims filed later than that date may be declined or reduced unless:

  • it is not reasonably possible to submit the claim in that time; and 
  • the claim is submitted within one year from the date incurred. This one-year period will not apply when the person is not legally capable of submitting the claim.

The Claims Administrator will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested from the claimant. The Plan reserves the right to have a Plan Participant seek a second medical opinion.

A request for Plan benefits will be considered a claim for Plan benefits, and it will be subject to a full and fair review. If a claim is wholly or partially denied, or if there is any other adverse benefit determination, the Claims Administrator will furnish the Plan Participant with a written notice. The written notice will contain the following information, in addition to any other information required by law:

  • the specific reason or reasons for the adverse benefit determination; 
  • specific reference to those Plan provisions on which the determination is based; 
  • a description of any additional information or material necessary to correct the claim and an explanation of why such material or information is necessary; and 
  • appropriate information as to the steps to be taken if a Plan Participant wishes to submit the claim for review.

A Plan Participant will be notified as to the acceptance or denial of a claim within the following time frames:

  • Urgent care claims: Within 72 hours of receipt of the claim, unless the Plan Participant fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan. In the case of such failure, the Plan Administrator will notify the Plan Participant of the specific information necessary to complete the claim within 24 hours after receipt of the claim by the Plan. The Plan Participant will then have at least 48 hours to provide the specified information. The Plan Administrator will then notify the Plan Participant of the acceptance or denial of the claim within 48 hours of the earlier of the Plan Administrator’s receipt of the specified information or the end of the period afforded the Plan Participant to provide the specified information
  • Pre-service claims: Within 15 days of the Plan’s receipt of the claim.
  • Post-service claims: Within 30 days of the Plan’s receipt of the claim.

If special circumstances require an extension of time for processing a non-urgent care claim, the Claims Administrator shall send written notice of the extension to the Plan Participant. The extension notice will indicate the special circumstances requiring the extension of time and the date by which the Plan expects to render the final decision on the claim. In no event will the extension exceed a period of 15 days from the end of the initial 15-day period for pre-service claims, or a period of 30 days from the end of the initial 30-day period for post-service claims.  If the extension is necessary due to the Plan Participant’s failure to submit the information necessary to decide the claim, the extension notice shall specifically describe the required information, and the Plan Participant will have at least 45 days from receipt of the notice to provide the specified information.

If a Plan Participant is not notified as to acceptance or denial of a claim within the time frames provided above, the claim shall be deemed denied. Note-Failing to respond to the claim within these time periods can have adverse effects on Rhodes.  The participant will be free to sue for benefits (rather than follow the administrative appeal process), and the court will be able to review the denial de novo (the standard is typically abuse of discretion when the plan follows the procedural requirements).

Claims Review Procedure. In cases where a claim for benefits payment is denied in whole or in part, or if there is any other adverse benefit determination, the Plan Participant may appeal the denial. This appeal provision will allow the Plan Participant to:

  1. Request from the Plan Administrator a review of any claim for benefits. Such request must include: the name of the Employee, his or her Social Security number, the name of the patient and the Group Identification Number, if any. 
  2. File the request for review in writing, stating in clear and concise terms the reason or reasons for this disagreement with the handling of the claim. 
    The request for review must be directed to the Plan Administrator or Claims Administrator within 180 days after the claim payment date or the date receipt of the notification of denial of benefits.

A review of the denial or other adverse benefit determination will be made by the Plan Administrator and the Plan Administrator will provide the Plan Participant with a written response as follows:

  • Urgent care claims: Within 72 hours of receipt of the Plan Participant’s request for the review of the adverse benefit determination.
  • Pre-service claims: Within 30 days of the Plan Participant’s request for review of the adverse benefit determination.
  • Post-service claims: Within 60 days of the Plan Participant’s request for review of the adverse benefit determination.

If the Plan Participant is not notified of the plan’s decision within the time frames provided above, the Plan Participant may deem the claim denied. As noted above, failing to respond to the claim within these time periods will permit a reviewing court to review the denial de novo, rather than abuse of discretion.

The Plan Administrator’s written response to the Plan Participant shall cite the specific reason or reasons for adverse determination, the specific Plan provision(s) upon which the determination is based, and any other information required by law.

A Plan Participant must exhaust the claims appeal procedure before filing a suit for benefits.

For further information, please see a copy of the Summary Plan Description of the Welfare Benefit Plan.

 

 

Note: The Rhodes College Handbook is not a contract of employment, nor should it be construed to create a contract with the College. Rhodes reserves the right to make future changes to its policies, practices, and fringe benefits. If such changes occur, the College will inform employees of such changes and their effect, if any. If you have questions, please contact The Rhodes Human Resources Department at hr@rhodes.edu.