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How to file a claim for FSA, PHA and DCA


How to file a claim for FSA, PHA and DCA

Motorola Mobility wants to be sure that you, your covered dependents and your beneficiaries all receive the full benefits that you and they are eligible to receive under the Plan.


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Denied benefits requests and the appeals process

Once you apply for a specific benefit, youíll receive a decision from the claims administrator in writing. The claims administrator may either approve or deny your request. The following section addresses what happens if your benefits request is denied. Youíll also find more information about your right to appeal these decisions.

If your benefits request is denied, youíll receive a written notice that explains this denial. The notice will contain the following information:

  • The specific reasons for the denial
  • The specific Plan provisions upon which the denial is based
  • A description of any additional material or information youíll need to perfect the claim for benefits, as well as an explanation of why those materials are necessary
  • An explanation of the appeal for this denial, including a statement of your right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on final review
  • In the case of health care benefits, the written denial notice also informs you of any specific rule, guideline or protocol that was relied upon, or a statement that such rule, guideline or protocol was relied upon, and that you may request a copy of it free of charge
  • If the adverse determination is based on a medical necessity or experimental treatment exclusion, an explanation of the scientific or clinical judgment or a statement that you may request such explanation free of charge
  • In the case of an urgent care claim, a description of the expedited review process

You have the right to request and receive reasonable access to and copies of relevant documents, records and other information thatís either in the possession of Motorola Mobility or the applicable claims administrator. Youíre also entitled to receive these documents free of charge. Relevant documents, records and other information are those that:

  • Were relied upon in making the benefit determination
  • Were submitted, considered or generated in the course of making the benefit determination
  • Demonstrate compliance with the Planís administrative processes or safeguards
  • In the case of health care benefits, constitute a statement of the Planís policy or guideline regarding the benefit for your diagnosis, whether relied upon or not

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Your right to appeal

If an initial claim for benefits is denied, in whole or in part, in a letter from the claims administrator or otherwise, you may request a review of the denial. Your request for review must be in writing, and it should contain the reasons why you believe youíre entitled to benefits, as well as any additional information or documentation to support your claim.


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Second level of review

If your appeal is denied, you may submit a written second-level appeal of that denial.

Youíll receive the final decision about your appeal in writing. This decision will give you the specific reasons for the decision and also provide you with the corresponding Plan provision(s). The decisions are final and binding on all parties except as required by law.

You or your covered dependents must exhaust all of the internal administrative remedies described above prior to bringing an action for benefits under the Plan under Section 502(a) of ERISA.


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Request for review

Plan/program

Send request for review to:

 

First level of review

Second level of review

Health Care Flexible Spending Account (FSA)

Personal Health Account (PHA)

Dependent Care Account (DCA)

Mail:

SHPS Spending Accounts
P.O. Box 34700
Louisville, KY 40232

Fax: 866-643-2219

Deadline for submitting written request for review

180 days from notification of denial

Date for final decision on appeal

Decision will be made within 30 days of receipt of your written appeal

Date for filing suit in federal court

180 days after final denial of appeal

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