Options to Resolve Denied Reimbursements and Other Funding Issues
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.
Requesting an exception and filing an appeal are two ways of resolving a concern about a reimbursement request (such as a “denied” or “not approved” status), funding qualification, or funding contribution. In most situations, it isn't necessary to file an exception or appeal to resolve these concerns. Via Benefits representatives are trained to assist you in reviewing your account and resolving your concerns.
Eligibility, Qualification, and Contribution Amounts
A reimbursement account is provided according to the terms specified in your benefit plan document.
Your former employer or benefits provider:
Establishes the contribution amount and frequency for each eligible participant.
Determines any qualification requirements necessary to access the funds designated for you.
Contact Via Benefits for a review of your account if you believe your qualification status is in error or you disagree with the contribution amount provided. Many issues can be addressed quickly with the assistance of one of our representatives, who’s able to fix errors or help you request an exception. You also have the right to file a formal appeal as explained below.
Reimbursement and Exception Requests
Reimbursement Requests
Via Benefits processes reimbursement requests according to the terms of the plan document and IRS rules. If an expense is denied, the specific reason(s) for the denial are provided in the Explanation of Unpaid Expenses (EOUE).
An expense in a “not approved” status can often be resolved through the submission of additional documentation to meet the plan rules. Contact us to discuss any additional options if you feel you've submitted all required documentation, and your concern isn't resolved.
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. One of our representatives can review your account to determine if there’s any action available to resolve the denial. An exception request may be needed for a denied expense when the plan document rules weren't met, and there are extenuating circumstances that could explain why the request should be approved.
Exception Requests
Contact us to request an exception over the phone or in writing. Be prepared to provide proof of your extenuating circumstance. Some employers require all requests for exception be submitted as a written appeal. A Via Benefits representative can provide you with these instructions. Please be aware not all former employers or benefits providers allow for exceptions or appeals.
Appeal Requests
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 or other communication. You must file the appeal within 180 days of the date you received notice of the action in concern. 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, a Letter of Medical Necessity, proof of extenuating circumstance, or a request for an exception to the plan rules.
You'll receive a written communication of the appeal decision within 30 days of receipt. If your appeal is denied, the communication provides information on next steps.
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.
