We will not review your claim unless you demonstrate that you gave the carrier the opportunity to reconsider its initial denial. Providers may use this procedure only on behalf of and with the specific written consent of the member and are required to demonstrate that the member has assigned all of his or her rights to the provider with regard to that particular claim. You may ask us for a review if the carrier fails to respond within 30 days after your written request for reconsideration or 30 days after you have supplied additional information. In this case, we must receive a request for review within 120 days after your request to the carrier for reconsideration or the date you were notified that the carrier needed additional information. If you decide to seek judicial review of the denial of a claim, you must file suit no later than December 31 of the third year after the year in which the care or service was provided.
Federal law governs claims for relief that relate to benefits under the plan.
Damages recoverable under Federal law are limited to the amount of benefits in dispute. Such legal actions must be brought against this agency. These actions are limited to the record that was before us and that was the basis of our decision to disallow the benefit, thus affirming the carrier s decision. Privacy Act Statement.