10-10-2022 Council Packet - Laserfiche WebLink

Home Browse Search

© 2019 Hitesman & Wold, P.A. MEDSURETY, LLC Cafeteria Plan 1-888-816-4234, www.medsurety.com Basic Plan Document 23 (d) Automatic Reimbursement of Recurring Claims – Individual Premium Feature and Individual Medical Premium Feature. If selected in the Adoption Agreement, the Plan provides for automatic reimbursements of certain eligible expenses under the Individual Premium Feature and/or Individual Medical Premium Feature. To receive automatic reimbursements as provided herein, the Participant must complete and return a form to the Plan Administrator electing to do so. A Participa nt must submit a claim for the first eligible expense incurred during a particular Plan Year purs uant to the standard paper claim procedures described above. Upon approval of that claim, the Claims Administrator will provide the claim reimbursement by paying the reimbursed amount directly to the insurance carrier. Thereafter, the Claims Administrato r will automatically reimburse, without submission of an additional paper claim, an amount equal to the amount of the first claim by paying that amount to the insurance carrier at the appropriate payment interval. For purposes of this provision, the appropriate payment interval shall be the time period reflected in the first claim for which the services or coverage was provided (e.g., weekly, monthly, quarterly, etc.). Notwithstanding anything herein to the contrary, reimbursements for recurring claims shall be made only after the eligible expense was incurred. In the event the amount of the eligible expense or the identity of the insurance carrier changes, the Participant must submit a paper claim with respect to the new amount or insurance carrier. 6.9 Determination of Benefits. This Section addresses the claims determination and appeal procedures for reimbursement-type Optional Benefits chosen in the Adoption Agreement, and the provisions of general applicability, regardless of whether any portion of this Plan is subject to ERISA. Claims determination and appeal procedures for other Optional Benefits shall be handled in accordance with the governing documents for those Optional Benefits. (a) Initial Determination. The Plan Administrator, or Plan Administrator’s designee, shall notify a person within thirty (30) days of receipt of a written claim for benefits of that person's eligibility or non-eligibility for benefits under the Plan. If it is determined that a person is not eligible for benefits or for full benefits, the notice shall set forth: (1) The specific reasons for the denial; (2) A specific reference to the provision of the Plan on which the denial is based; (3) A description of any additional information or material necessary for the claimant to perfect the claim and an explanation of why it is needed; and (4) An explanation of the Plan's claims review procedure and other appropriate information as to the steps to be taken if the Participant wishes to have the claim reviewed. If the Plan Administrator, or Plan Administrator’s designee, determines that there are special circumstances requiring additional time to make a decision, the Plan Administrator, or Plan Administrator’s designee, shall notify the Participant of the special circumstances and the date by which a decision is expected to be made, and may extend the time for up to an additional fifteen (15) days. (b) Appeals. If a Participant is determined by the Plan Administrator, or Plan Administrator’s designee, not to be eligible for benefits, or if the Participa nt believes that he or she is entitled to greater or different benefits, the Participant shall have the opportunity to have the claim reviewed by the Plan Admi nistrator, or Plan Administrator’s designee, by filing a petition an appeal within one hundred eighty (180) days after receipt by the Participant of the notice issued by the Plan Administrator, or the Plan