Appealing Denied Reimbursements
This article applies to you if you have a Via Benefits reimbursement account, sometimes known as a Health Reimbursement Arrangement*.
This article explains how reimbursement requests are processed, why expenses might be denied, and the options available if you disagree with a denial. It also outlines the appeal process, including when an appeal may be appropriate, how to submit one, and what to expect during review.
Note: This information is based on employer rules and may not apply to you.
Reimbursement Request Processing
Via Benefits processes reimbursement requests according to the terms of the Summary Plan Description (SPD) provided by the plan administrator and applicable IRS rules.
Denied Expenses
If an expense is denied, the specific denial reason is provided in your Explanation of Payment (EOP) or Explanation of Unpaid Expenses (EOUE). Your EOPs and EOUEs are available on the website. To learn how to view these documents, read Your Reimbursement Account Statements.
An expense is denied if it doesn't meet the plan rules for reimbursement. For example, the expense may not be eligible for reimbursement or may have been submitted after the deadline.
Denied expenses are final and can't be approved by submitting additional documentation. Therefore, no further action is required unless you believe the expense was denied in error.
If your expense wasn’t denied but is in a Not Approved status, read Resolving Not Approved Reimbursements to learn about the steps you can take to resolve the issue.
Appeal Process
You have the right to submit a written appeal for any adverse determination within 180 days of receiving the denial notice. However, many concerns can be resolved without filing an appeal, so we encourage you to contact Via Benefits first.
You can call us at 1-866-322-2824 (TTY: 711) or submit a Help Ticket through the Reimbursement Center. Our representatives are trained to review your account, explain the denial, and help address your concerns.
If your concerns aren’t resolved after speaking with a representative or submitting a Help Ticket, you may file an appeal. During the appeal process, the plan administrator reviews the denied expense to confirm it was processed according to the terms of the SPD and IRS rules.
Appeal Reasons
Examples of situations that may warrant an appeal include:
Extenuating circumstances, such as a physical or mental incapacity, prevented you from meeting the plan requirements.
An expense was incurred outside the coverage period, and you believe an exception should be considered.
An expense was submitted after the submission deadline, and extenuating circumstances affected your ability to submit it on time.
You believe you received incorrect information regarding eligible expenses or submission deadlines.
Submitting an Appeal Request
You may submit an appeal to ask for additional review of the denied expense.
Claim Submission Deadline Denial
Most appeals must be submitted in writing and can’t be accepted over the phone. However, if permitted by the plan administrator, our representative can submit a request for a claim submission deadline extension during a phone call. Be prepared to provide the reason you were unable to meet the deadline.
All Other Denials
If you're appealing a denial for any reason other than a missed claim submission deadline, you must submit your appeal in writing and mail it to your plan administrator.
Written Appeal Guidance
To expedite processing, your appeal request needs to include:
A statement explaining why you believe the expense should not have been denied
Information and documentation that supports your request
Expense details
Expense Details
Include a copy of the EOP or EOUE that lists the denied claim so we can identify the person and issue in question.
Your EOPs and EOUEs are viewable on the website. Read Your Reimbursement Account Statements to learn how to find them.
If you don’t include an EOP or EUOE with your appeal, you must provide the following information:
Account holder name
Account holder's Social Security number (or last 4 digits) and ZIP Code
Expense number
Expense amount
Dates of service (start and end dates)
Covered person’s name (if different from account holder)
Expense description
Employer name
Date of the denial or change in status
Reason for denial or change in status
Mailing Your Request
Send your appeal request, as outlined above, to the address provided on your Reimbursement Request Form, EOP, or EOUE.
Receiving the Appeal Decision
The plan administrator's decision will be sent within 30 days of receiving your appeal. If you don't agree with the decision, you can file a second appeal by following the directions included with your initial appeal denial.
If your appeal is denied, the appeal decision will state:
Specific reasons for the denial
Plan provisions relied upon
Your rights to review relevant documents upon request at no charge
Internal rules, guidelines, protocols, or other criteria relied upon (free of charge upon request)
After your second appeal, your right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974, if applicable.
If you don't agree with the decision after your second appeal or the plan administrator fails to adhere strictly to the appeal process, you may have the right to request an external review by an independent review organization.
*Via Benefits reimbursement accounts are administered by Extend Health, LLC.