Appealing Denied Reimbursements
This article applies to you if you have a Via Benefits reimbursement account (sometimes known as a Health Reimbursement Arrangement)*.
Note: This information is based on employer rules and may not apply to you.
Via Benefits processes reimbursement requests according to the terms of the plan document and IRS rules. If an expense is denied, the specific reasons for the denial are provided in the Explanation of Payment (EOP) or Explanation of Unpaid Expenses (EOUE). An expense in a denied status means the expense doesn't meet the plan rules for reimbursement, such as being an eligible expense or being submitted for reimbursement within the submission deadline. No action is needed for denied expenses. Denied expenses can't be resolved through the submission of additional supporting documentation. Read Resolving Not Approved Reimbursements to learn about resolving not approved expenses.
Please contact us if you disagree with an expense denial. You can call us or submit a Help Ticket in the Reimbursement Center. Via Benefits representatives are trained to assist you in reviewing your account and resolving your concerns. If speaking with a representative or emailing us doesn't resolve your concerns, you can file an appeal. During an appeal, the plan administrator reviews the denied expense to verify it was processed according to the terms of the plan document and IRS rules. You may always submit a written appeal for any adverse determination. However, in most situations, it isn't necessary to file an appeal to resolve your concerns.
Viewing Denial Reasons
The EOP, EOUE, or the Activity Details on the website or mobile app tell you the reason the request was denied.
Website Activity Details
Mobile App Activity Details
On the mobile app, under Account Updates, you can see your Denied Expenses. Select the Denied link to see the Activity Details. The Activity Details provide the reason an expense was denied. If you don’t agree with the denial reason, please call us for assistance.
Submitting an Appeal Request
You may submit an appeal to ask for additional review. An appeal can’t be accepted over the phone. All appeal requests must be written and sent by mail. Send your appeal request, along with a statement that explains the reason for the appeal, to the address provided on your Reimbursement Request Form, EOP, EOUE, or Loss of Funding Letter. Your EOPs and EOUEs are viewable on the website. Read Your Reimbursement Account Statements to learn how to find them.
You have 180 days from the date you receive a denial to file an appeal with your plan administrator. Your appeal should state why the expense shouldn't have been denied and any additional evidence, testimony, facts or documentation supporting your claims.
You can also ask questions, submit written or oral statements or comments and review (at no additional charge) documents or other information relevant to you appeal.
A written appeal needs to be as complete as possible and contain the following information to improve processing.
Including the EOUE, or other supporting documents, with the appeal is helpful in identifying the person and issue in question.**
Account holder name**
Account holder Social Security number or last 4 digits of SSN 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
A statement that explains the reason for the appeal
The statement needs to indicate why you feel the expense should be covered, or why funding should be provided, reinstated, or the amount reviewed. Include any information that would help substantiate or determine if the appeal can be approved.
Supporting documents that may include additional expense details, such as a Letter of Medical Necessity, proof of extenuating circumstance, or a request for an exception to the plan rules.
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 using the same process as you followed for your first appeal.
If adverse, the 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 criterion relied upon (free of charge upon request)
After you 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
Common Reasons for an Exception or Appeal Request
Extenuating circumstances prevented you from meeting the plan rules due to a physical or mental incapacity.
You didn't receive plan information because the address on file was outdated.
Qualification was met after the enrollment period due to timing with the insurance carrier’s application process.
An expense was incurred outside of the coverage period.
An expense was submitted outside of the submission period.
You haven't met one or more of the plan rules and would like another chance to regain qualification.
You feel you were provided misinformation regarding eligibility, qualification, enrollment requirements, eligible expenses, or expense submission deadlines.
You're no longer enrolled or eligible to be enrolled and lost qualification as of a specific date because of changes in qualification or eligibility.
You feel you weren't notified about initial or ongoing enrollment requirements.
*Via Benefits reimbursement accounts are administered by Extend Health, LLC.