Understanding Declined Health Reimbursement and Proof of Coverage Submissions and How to Resolve Them
Health reimbursement or proof of coverage submissions can be declined due to various compliance reasons and documentation issues. Below, we outline the primary causes for declined submissions, the distinctions in compliance terminology, the required documents, and steps to resolve issues efficiently.
Common Reasons for Declined Submissions
1. Non-Compliance with Minimum Essential Coverage (MEC)
Your reimbursement submission may be declined if your health plan does not satisfy Minimum Essential Coverage (MEC) requirements outlined by the Affordable Care Act (ACA). Specifically, MEC-compliant plans must:
Not impose annual coverage limits.
Cover 100% of preventive health care.
For example, submissions with plans that have maximum expense provisions (such as annual dollar limits on coverage) or that only meet "Minimum Creditable Coverage" (different from MEC) will be considered non-compliant. This distinction is critical for Health Reimbursement Arrangements (HRA) eligibility, including Individual Coverage HRA (ICHRA) and Qualified Small Employer HRA (QSEHRA).
2. Ineligible Health Plans for ICHRA Submissions
For ICHRA, only individual major medical plans with a metal tier designation (Bronze, Silver, Gold, Platinum) are eligible. Group plans or plans lacking a metal tier designation will result in submission rejection.
3. Missing or Incomplete Documentation
Proof of coverage or premium verification might be marked "non-compliant" if required details are missing. Common documentation errors include:
The absence of premium amounts if a reimbursement claim is involved.
Documents outdated by more than 30 days.
Missing critical details, such as name, plan name, provider, or a statement confirming backdated coverage if claiming for past months.
For such cases, submitting current documents (e.g., monthly insurer bills or Benefits Summary documents) showing all required fields can typically resolve the issue.
Required Documentation for Compliance Resolution
To resolve compliance issues, ensure that your documentation:
Clearly displays your name (or indicates dependent status).
Includes the premium amount if reimbursement is being claimed.
Is dated within the last 30 days.
Includes plan provider details (e.g., carrier logo, metal tier, or plan name).
Matches official premium documentation precisely.
Additional documents, such as proof of backdated coverage, may also be required depending on the case.
Interaction with the Compliance Team
While the Compliance team does not handle direct client communication, there are steps you can follow to request a case review:
Upload the necessary documents and details about the issue to your account on the portal.
Clearly note your concerns and request a detailed review.
The team will review your case and provide a response via email.
Takeaways
By understanding compliance requirements, distinguishing between MEC and other coverage types, and providing the appropriate documentation, most issues with declined submissions can be resolved easily. Always double-check that your submissions meet ACA standards and include complete, accurate documentation. For any further queries, refer to the Frequently Asked Questions (FAQs) related to your plan and submission process.