Appeal Rights

This document contains important information that you should retain for your records.

This document serves as notice of benefit determination. We may have declined to provide benefits, in whole or in part, for the requested treatment or service described o the front side of this document. If you think this determination was made in error, you have the right to appeal (see below for information about your appeal rights).

Important Information about Your Appeal Rights.

What if I need help understanding this denial?
Contact Customer Service at the number located on the front of your explanation of benefits and on your Identification Card. If you need assistance understanding this notice or our decision to deny you a service or coverage.

What if I don’t agree with this decision?
You have a right to appeal any decision not to provide or pay for an item or service (in whole or in part). As part of our standard appeal process, you have 180 days from receipt of this notice to file an appeal. Failure to comply with this timeframe may constitute forfeiture of your right or your designated agent’s right to appeal a claim denial, partial payment or service rejection. How do I file an appeal? Send your request and any supporting documentation to:

FBC Appeals Department
Fringe Benefit Coordinators, Inc.
2005 Cobbs Ford Rd, STE 401A
Prattville, AL 36066

Where do I submit an IDR Notice under the No Surprises Act if I disagree with the claim payment amount?
If you wish to initiate the IDR process under the No Surprises Act for this claim, please submit your written IDR Notice to the following address:

FBC IDR Notice
Fringe Benefit Coordinators, Inc.
2005 Cobbs Ford Rd, STE 401A
Prattville, AL 36066

Please include the claim number, date of service, and all supporting documentation to help us process your request promptly.

What if my situation is urgent?
If your situation meets the definition of urgent under the law, your review will generally be conducted within 72 hours. Generally, an urgent situation is one in which your health may be in serious jeopardy or, in the opinion of your physician, you may experience pain that cannot be adequately controlled while you wait for a decision on your appeal. If you believe your situation is urgent, you may request an expedited appeal by contacting the customer service phone number listed on your ID card. If your request does not meet the requirements for an expedited review, we will follow the standard appeal timeframe for pre-service reviews which is 30 calendar days. You, your authorized representative, or healthcare provider will receive a written determination of our review.

Who may file an appeal?
You or someone you name to act for you (your authorized representative) may file an appeal. The authorized representative and the applicant request must both be in writing accompanied by a signature, unless the applicant is unable to sign.

Can I provide additional information about my claim?
Yes, you may supply additional information by contacting customer service by phone or in writing. Please submit requests to careadvocacy@myfringebenefits.com
or call (833) 236-3229

Can I request copies of information relevant to my claim?
Yes, you may request copies (free of charge). If you think a coding error may have caused this claim to be denied, you have the right to have billing and diagnosis codes sent to you, as well. You can request copies of this information by contacting Customer Service. Please submit requests to careadvocacy@myfringebenefits.com or call (833) 236-3229

What happens next?
If you appeal, we will review our decision and provide you with a written determination. Standard pre-service appeals are processed in 30 calendar days
from receipt. Post or after service appeals are reviewed within 60 calendar days from receipt or your request. You, your authorized representative, or healthcare provider will receive a written determination of our review and outcome of the appeal. If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision.

Other resources to help you:
For questions about your rights, this notice, or for assistance, you can contact:
the Employee Benefits Security Administration at 1-866-444-EBSA (3272).