HCFSA claim procedures
Simply submit a claim form, called a request for withdrawal, for the eligible healthcare expenses that you have incurred. Claim forms are available from your Benefits representative, by calling UnitedHealthcare customer service at 800 387 7508 or by visiting the UnitedHealthcare website at www.myuhc.com.
You must include proof of the expenses incurred along with your claim form. Proof can be a bill, invoice or an Explanation of Benefits form (EOB) from any group medical/dental plan under which you are covered. An EOB will be required for reimbursement of services that are usually covered under group medical and dental plans, such as charges by surgeons, doctors or hospitals. In these cases, an EOB will verify the amount of your out-of-pocket expenses after benefit payments under other group medical/dental plans.
HCFSA claims should be submitted to the following address:
Health Care Account Service Center
P.O. Box 981506
El Paso, TX 79998-1506
P.O. Box 981506
El Paso, TX 79998-1506
If you prefer, you can submit your claims via fax at 915 231 1709.
Only expenses incurred while you are a participant in the HCFSA are reimbursable. In addition, expenses incurred during one plan year cannot be reimbursed during another plan year. An expense is considered incurred when services are provided, not when you are billed or when you pay for care.
You can submit a claim form as often as you like. If you have established an HCFSA, your total annual calendar year contribution is available immediately. You can request reimbursement for eligible expenses up to your annual contribution amount as soon as eligible expenses are incurred.
HCFSA claims will be accepted until March 31 of the following year. Any claims submitted prior to March 31 and denied due to a lack of proper documentation will be reconsidered only if the appropriate documentation is submitted and received by UnitedHealthcare by April 30. In accordance with IRS regulations, amounts contributed to your HCFSA during the plan year but remaining in your account after March 31 of the following year cannot be returned to you or used to reimburse expenses incurred in a subsequent plan year. These amounts are forfeited.
Remember, you cannot be reimbursed for any expenses paid by an employer-sponsored medical or dental plan. Any expenses reimbursed by your HCFSA cannot be included as a deduction or credit on your income tax return.
If you enroll in a UnitedHealthcare Choice or Value PPO plan and elect to contribute to the HCFSA, your medical and prescription drug copayments and coinsurance amounts will automatically roll over to the HCFSA. Medical and prescription drug expenses that are not covered under your UnitedHealthcare Choice or Value PPO plans, including copayments and coinsurance amounts, are automatically submitted to your HCFSA for reimbursement. This automatic claim submission feature eliminates extra paperwork and makes it more convenient for you to use your HCFSA.
If you do not want to use the automatic submission feature, call UnitedHealthcare customer service at 800 387 7508 in order to request that it be discontinued. You can also discontinue automatic claim submission by visiting the UnitedHealthcare website at www.myuhc.com.
If you have medical coverage through another carrier, you cannot select the automatic claim submission feature. In addition, automatic submission cannot be selected for your spouse if your spouse is not covered under Stryker's Health Plan.
Unless you use your Consumer Account Card, an HCFSA claim form must be submitted for any other types of expenses, such as dental or vision expenses that are not covered by a plan administered by UnitedHealthcare.
UnitedHealthcare will decide your claim no more than 30 days after it is received as long as all needed information was provided with the claim. This time period may be extended for an additional 15 days if additional information is needed to process the claim when necessary due to matters beyond the control of UnitedHealthcare or if your claim is incomplete. You will be advised in writing of the need for an extension during the initial 30-day period, and a determination will be made no more than 45 days after the date the claim was submitted. If the extension is needed because your claim is incomplete, the notice will specifically describe the information necessary to complete your claim and you will be allowed 45 days from receipt of the notice to provide the information. The timeframe for deciding the claim will be suspended from the date the notice of extension is sent until the date on which you respond to the notice. If you provide the requested information within the 45 days, your claim will be decided within 15 days after the information is received. If you do not provide the requested information within the prescribed timeframe, your claim will be denied. An adverse benefit determination notice will explain the reason for the adverse benefit determination, refer to the part of the plan on which the adverse benefit determination is based and explain claim appeal procedures.
If UnitedHealthcare sends you a notice of adverse benefit determination, whether that is for the entirety of your claim for a benefit or a part of the claim, you will receive a written notice that will provide:
- The specific reason or reasons for the adverse benefit determination
- Reference to specific plan provisions on which the determination was based
- A description of any additional material or information necessary to complete the claim and an explanation of why such material or information is necessary
- A description of the steps you must follow (including applicable time limits) if you want to appeal the adverse benefit determination, including, in the case of an adverse benefit determination on a claim for reimbursement under the HCFSA:
- Your right to submit written comments and have them considered
- Your right to receive (upon request and free of charge) reasonable access to, and copies of, all documents, records and other information relevant to your claim
- Your right to bring a civil action under Section 502 of ERISA if your claim is denied on appeal
- If the claim administrator relied on an internal rule, guideline, protocol or other similar criterion in denying your claim, either:
If you have a question or concern about an adverse benefit determination, you may informally contact a UnitedHealthcare customer service representative before requesting a formal appeal. The customer service telephone number is 800 387 7508. If the customer service representative cannot resolve the issue to your satisfaction, you may request a formal appeal.
If you wish to request a formal appeal of an adverse benefit determination, you should contact customer service to obtain the UnitedHealthcare address where the appeal should be sent. Your appeal should be submitted in writing to that address and should include your name, a description of the claim determination that you are appealing, the reason you believe the claim should be paid and any written information to support your appeal.
Your first level appeal request must be made in writing to the claim administrator within 180 days after you receive the written notice that your claim has been denied in whole or in part. If you do not file your appeal within this time period, you will lose the right to appeal the denial.
Your written appeal should set out the reasons you believe that the claim should not have been denied and should also include any additional supporting information, documents or comments that you consider appropriate. At your request, you will be provided, free of charge, with reasonable access to, and copies of, all documents, records and other information relevant to the claim.
UnitedHealthcare will review the first level appeal request and notify you of the decision in writing within 30 days from receipt of a request for appeal of a denied claim. If you are not satisfied with the first level appeal decision, you have the right to request a second level appeal from UnitedHealthcare. Your second level appeal request must be submitted in writing to UnitedHealthcare within 60 days from receipt of the first level appeal decision. The second level appeal will be conducted and you will be notified by UnitedHealthcare of the decision in writing within 30 days from receipt of a request for a second level appeal.
UnitedHealthcare has the exclusive right to interpret and administer Stryker's healthcare spending account plan, and these decisions are conclusive and binding.
The review will take into account all comments, documents, records and other information relating to the claim that you submit without regard to whether such information was submitted or considered in the initial benefit determination. The review will not give deference to the initial adverse benefit determination. In addition, the individual who decides your appeal will not be the same individual who denied your initial claim and will not be that individual's subordinate.
UnitedHealthcare will conduct a full and fair review of your appeal. The appeal may be reviewed by:
- an appropriate individual(s) who did not make the initial benefit determination; and
- a health care professional who was not consulted during the initial benefit determination process.
Once the review is complete, if UnitedHealthcare upholds the adverse benefit determination, you will receive a written explanation of the reasons and facts relating to the adverse benefit determination.
Your Plan offers two levels of appeal. If you are not satisfied with the first level appeal decision, you have the right to request a second level appeal from UnitedHealthcare within 60 days from receipt of the first level appeal. UHC must notify you of the benefit determination within 30 days after receiving the completed appeal.
Note: Upon written request and free of charge, any covered persons may examine documents relevant to their claim and/or appeals and submit opinions and comments. UnitedHealthcare will review all claims in accordance with the rules established by the U.S. Department of Labor. UHC's decision will be final.
The table below describes the time frames in an easy to read format which you and UnitedHealthcare are required to follow.
* UnitedHealthcare may require a one-time extension of no more than 15 days only if more time is needed due to circumstances beyond their control.
You will be notified in writing of the decision on appeal. If the decision upholds the initial adverse benefit determination, the notification will provide:
- The specific reason or reasons for the adverse benefit determination
- Reference to specific plan provisions on which the determination was based
- A description of your right to receive (upon request and free of charge) reasonable access to, and copies of, all documents, records and other information relevant to your claim
- If an internal rule, guideline, protocol or other similar criterion was relied on in denying your claim, either:
- A description of the specific rule, guideline, protocol or criterion relied on
- A statement that a copy of such a rule, guideline, protocol or criterion will be provided free of charge upon request
- A statement of your right to bring a civil action under Section 502 of ERISA
If you receive an adverse benefit determination based on a determination that an individual is not eligible for benefits, you have 180 calendar days after receiving the adverse benefit determination notice in which to appeal the determination to the plan administrator. Your appeal must be in writing. If you do not file an appeal within this 180-day period, you will lose the right to appeal the determination.
Your written appeal should state that it is an appeal, set out the reasons you believe that the claim should not have been denied and should also include any additional supporting information, documents or comments that you consider appropriate and describe the specific details of what happened to cause the issue resulting in ineligibility. At your request, you will be provided, free of charge, with reasonable access to, and copies of, all documents, records, and other information relevant to the claim.
Submit your appeal to the following address:
Stryker Benefits Committee
Attn: Health Plan Administrator
Stryker
1901 Romence Road Parkway
Portage, MI 49002
Attn: Health Plan Administrator
Stryker
1901 Romence Road Parkway
Portage, MI 49002
The plan administrator will review and decide your appeal within a reasonable period of time but no longer than 60 days after it is submitted. The review will take into account all comments, documents, records and other information relating to the claim that you submit without regard to whether such information was submitted or considered in the initial benefit determination. The review will not give deference to the initial adverse benefit determination. In addition, the individual who decides your appeal will not be the same individual who decided your initial adverse benefit determination and will not be that individual's subordinate. The decision of the plan administrator is final and binding on all individuals claiming benefits under the plan.