More frequently asked questions

Although every medical claim is different, some reasons for denial may include other/primary coverage not processed, missing information, incomplete medical records, the services are not deemed medically necessary, failure to follow pre-authorization guidelines, or services are not a covered benefit.

Other helpful tools include the NALC HBP member portal. To understand why you received a denial, review the description listed at the bottom of the explanation of benefits (EOB) associated with the date of service in question.

If the denial is related to a prescription, you may be able to speak with someone at the pharmacy to determine the reason for denial (e.g., prior authorization clinical criteria not met, refill too soon, prescription defined as over-the-counter medication, step therapy is required, or other).

However, if you are unable to determine the reason for denial at the pharmacy level, make sure to reach out to the Plan, or log in to your CVS Caremark app, where you can review the status of your medication request.

Within six months of our initial decision, you may ask us in writing to review or reconsider our denial. It is important that you include a statement as to why you believe our initial decision was wrong based on our official provisions in the brochure, and include copies of physicians’ letters, operative reports, bills, and/or medical records to support your claim.

Keep in mind that the EOB from the Plan is not an invoice. Once you have carefully reviewed the EOB statement for accuracy, any balance due should be sent to the rendering provider or facility. If you suspect the provider has charged you for services that you did not receive, or duplicated charges for the same service, reach out to the billing office, as there might be an error.

Normally processing may take up to 45 days. Once finalized, coverage will begin on the first day of the following month.

Per cms.gov, opt-out and non-participating providers are defined as follows:

• “Doctors or other health care providers who don’t want to work with the Medicare program may ‘opt out’ of Medicare.”
• “Some providers who don’t accept assignment still choose to accept the Medicare-approved amount for services on a case-by-case basis. These providers are called ‘non-participating’.”