If your claim is denied, you have the right to ask the Plan to review the decision. The appeal process includes:
Claims Appeal and Review Process
- Two levels of internal appeal, and
- An external review by an independent review organization (IRO), if you remain dissatisfied after completing the internal appeals process.
Each appeal is reviewed fairly by someone who was not involved in the previous decision. You may submit additional information during the appeal process.
First-Level Appeal
If you disagree with a claim decision, submit a written appeal that includes:
- Your name
- Member ID number
- Group health plan name
- A brief explanation of why you disagree
- Any supporting documents
Appeal deadlines
- Concurrent Care Claims: Within 15 days of the denial.
- Post-Service Claims: Within 180 days of the denial.
Mail your appeal to:
Claims Administrator
c/o Employee Benefit Management Services, LLC (EBMS)
Attn: Claims Appeals
1550 Liberty Ridge Drive, Suite 330
Wayne, PA 19087
Second-Level Appeal
If you disagree with the first appeal decision, you may request a second review.
Appeal deadlines
- Concurrent Care Claims: Within 15 days of the first appeal decision.
- Post-Service Claims: Within 60 days of the first appeal decision.
Mail your appeal to:
Public Education Health Trust
Attn: Claims Appeals
2550 Denali St., Suite 1614
Anchorage, AK 99503
External Review
If you are not satisfied with the second-level appeal decision, you may request an external review by an independent organization. In most cases, you must complete both internal appeal levels before requesting an external review.
You generally must request an external review within 4 months of the final internal appeal decision.
Provider Payment Disputes
If a dispute only involves how much the Plan pays a provider, and you cannot be billed under the No Surprises Act, the dispute is resolved through the federal provider dispute process. In some cases, you may still appeal your claim while the provider payment dispute is being handled separately.
For more information
This section provides a summary of the Plan’s claims and appeals process. The complete appeals procedures, including all requirements, timelines, and applicable rights, are described in your Benefit Booklet. Benefit Booklets are available on the Plan’s website. If there is any difference between this summary and the Benefit Booklet, the Benefit Booklet will govern.