Was your claim denied or partially approved? Here's how to understand why, correct the issue, or submit a formal appeal.
Common denial reasons
Here are some common reasons that claims are denied or only partially approved:
The claim amount and receipt amount mismatch: the amount you're requesting to be reimbursed for does not match the payment amount on your receipt.
The claim date and receipt date mismatch: the date of expense and date on your receipt do not match.
The claim is outside of plan year: the expense was incurred outside of the benefit plan year.
A receipt is missing/invalid: the claim did not include a valid receipt.
The submitted expense is ineligible: the expense type/items are not eligible per the benefit program.
Other: the reason will be specified by your employer or plan administrator.
Partially approved claims
A claim may be partially approved when it includes both eligible and ineligible expenses. For example, if you submitted a claim that included an eligible and an ineligible expense, the eligible amount would be approved and you would see the following reason given on your claim "Ineligible expense: $[amount] — not covered by your [benefit account type]."
Here are some reasons you might see if your claim is partially approved:
“Dependent not covered: [$amount] — this dependent isn’t eligible for this expense under your [benefit account type].”
“Amount mismatch: [$amount] — claimed amount does not match your receipt.”
“Ineligible expense: [$amount] — not covered by your [benefit account type].”
You can appeal partially approved claims following the process outlined below for formal appeals. You can also submit a new claim for the amount that was not approved.
New corrected claim
Most claim denial reasons can easily be resolved by submitting a new and corrected claim.
Appeal deadlines
Contacting support
If you need additional information about your claim denial before making a formal appeal, contact Support before any shared deadlines.
You can formally appeal a denied or partially approved claim in writing. Review your plan rules to ensure your claim appeals meet any set deadlines within your plan documents.
Claim appeal deadlines
Benefit Account Type | Deadline to Appeal | Administrator’s Deadline to Respond |
Commuter | Consult plan documents | Within 60 days |
DC-FSA | Consult plan documents | Within 60 days |
FSA | 180 days after you received notice of denial | Within 60 days |
HRA | 180 days after you received notice of denial | Within 60 days |
ICHRA | 180 days after you received notice of denial | Within 60 days |
LP-FSA | 180 days after you received notice of denial | Within 60 days |
LSA | Consult plan documents | Within 60 days |
Other benefit deadlines
For benefits without deadlines listed, please consult your plan documents. All benefits have a shared deadline of 60 days for the administrator to respond.
How to submit an appeal
You can request an appeal in writing by following these steps:
Submit your appeal request to support using the attached form. You must send your appeal request within the deadlines listed above.
Your plan administrator will review your appeal request within their designated timeline and notify you of the outcome of your appeal.
About the appeal process
You are entitled to a review (appeal) of the claim determination if you have questions or do not agree.
To appeal, you or your authorized representative should submit a request in writing using the form attached below. Your request should include the group name (e.g., your employer), your name, your claim ID, and other identifying information shown on the claim details panel, as well as any comments, documents, records and other information you would like to have considered, whether or not submitted in connection with the initial claim.
You may also review documents relevant to your claim. Upon request and free of charge, you may receive reasonable access to and copies of all documents, records, and other information including any internal procedures or any specific rules, guidelines or protocols relied upon or used during the processing of your claim.
If you are appealing an adverse determination for your General Health Flexible Spending Account (FSA), Health Reimbursement Account (HRA), or Limited Flexible Spending Account (LP-FSA), then your written request for review must be filed within 180 days following receipt of the claims decision.
A review will be conducted and you will be notified of the decision within 60 days. Please review your plan documents or contact your plan administrator to confirm the specific appeals process available to you. If you do not agree with the final determination on review, and if your plan is governed by ERISA, you have the right to bring a civil action under Section 502(a). Please refer to your Summary Plan Description, or contact your employer, to confirm the applicability of ERISA to your plan.