Vision claims should be sent to: Vision Service Plan (VSP) P.O. Box 997105
Sacramento, CA 95899-7105
For vision questions about claims, eligibility, and benefits, please call your Member Services representative at:
Member Services Toll-free: 1-800-877-7195 Customer service representatives are available: Monday – Friday 5 A.M. to 7 P.M., Pacific Time Web site: www.vsp.com
Type of Plan When Claim Decisions Will Be Made (in calendar days)
Your Deadline for Initial Appeal
When Appeal Decisions Will Be Made
Medical (PHP) Dental (WDS) Vision Plans (VSP) Health Care Flexible Spending Account (HealthEquity)
(Group Health and Blue Shield resource information supplied in appendix)
The claims administrator will provide you with oral or written notification. If oral, a written or electronic notification will be given not later than three days after the oral notification.
For a pre-service claim, within 15 days of receipt of your request for review (which may be extended up to a total of 30 days if they need more time to process your claim for reasons beyond their control. If this applies, you will be notified before the end of the original 15-day period.) If your claim is incomplete, you will be notified within five days, and you will have at least 45 days to provide the necessary information. For a pre-service, urgent care medical claim, within 72 hours of receipt of your request for review. If your claim is incomplete you will be notified within 24 hours after it receives your claim, and you will have at least 48 hours to respond. In such case, a decision will be made within 48 hours of the earlier of the receipt of the information or the end of the period given to furnish the additional information.
For a post-service claim, within 30 days of receipt of your request for review (which may be extended up to a total of 45 days if they need more time to process your claim for reasons beyond their control. If this applies, you will be notified before the end of the original 30-day period.) If your claim is incomplete, you will have at least 45 days to provide the necessary information.
You have 180 days after receiving notice that your claim is denied to file an appeal, in writing, to the claims administrator.
For a pre-service claim (medical, dental), within 15 calendar days of receipt of your request for review. For a pre-service, urgent
care claim (medical),
within 72 hours of receipt of your request for review. If additional information is needed, you shall be notified and shall have at least 48 hours from receipt of the notice within which to provide the requested information.
For a post-service claim, within 30 calendar days of receipt of your request for review.
Extension: If the claims
administrator determines that special circumstances require an extension of time for processing the claim or appeal, you will be notified of that extension.
Urgent Care Claims
An urgent care claim is any claim for medical care or treatment where the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function or, in the opinion of a physician
would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. Ongoing Care Claims
Special rules apply where the Plan has approved an ongoing course of health care treatment either for a specific period of time or for a specific number of must follow the specific claims and appeals procedures established by the appropriate insurance carrier. See page 16-1 for more information.
A reduction or termination of the course of treatment before the approved time period or number of treatments will be considered a claim denial (except for plan amendment or termination). In this case, the claims administrator will notify you in advance so you can appeal the decision before the benefit is reduced or terminated.
You may request to extend the course of treatment beyond the approved time period or number of treatments. If this involves an urgent care claim, the claims administrator will notify you whether your request has been approved or rejected within 24 hours of receiving your request, as long as you make your request at least 24 hours before the approved time period or number of treatments expires.
Pre-Service Claims
The Plan can require approval of a service before you receive care (for example, preauthorization of a hospital stay). This is a pre-service claim. See the medical and vision sections of the SPD for more information on any services which require pre- approval.
Post-Service Claims
Post-service claims are all other claims that are not urgent care or pre-service claims.
If you failed to provide the information needed to process the claim, you will receive a notice from the claims administrator. The notice will identify the additional necessary information. You will have 45 days from the notice date to provide the additional information.
Claims Denial Notice for Benefits
You will receive a written or electronic notice of the claims decision from the claims administrator within the time prescribed in the chart on page 5-3. If your claim is denied, the notification will include: ● specific reasons for the denial;
● reference to the specific plan provisions on which the decision is based;
● a description of any additional material or information necessary for the claim to be completed and an explanation of why the
● a description of the Plan’s review procedures and their time limits, including your right to bring a civil action in court under Section 502(a) of ERISA following a claims denial on review;
● if an internal rule, guideline, protocol or other similar criterion was relied upon in the denial of the claim, you will be notified that the decision was based on the applicable items mentioned above, and that copies of the applicable material will be provided upon request (free of charge);
● if the denial is based on a medical necessity or experimental treatment or similar exclusion or limit, you will be given an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your medical circumstances, or notified that such explanation will be provided free of charge upon request; and
● for a claims denial involving an urgent care claim, a description of the expedited review process applicable to such claims.
If a medical judgment is involved, including denials based on a medical necessity or experimental treatment, the person reviewing your appeal will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment, who was not consulted in connection with the initial claim denial, and who is not the subordinate of anyone consulted in the claim denial. The medical or vocational experts whose advice was obtained will be identified.
If your claim is denied, and you disagree with the decision, your deadline to appeal is the same time limits specified in the chart on page 5-3. If you fail to appeal within the applicable time limit, then you lose your right to appeal and your right to file suit.