Group insurance appeals process

If the benefit claim of an individual who is eligible and properly enrolled in an insurance plan is denied by the plan carrier based on the plan’s contractual provisions, the appeal should be addressed to the carrier.

Contact information for the University’s Health and Welfare plan carriers is available online or by calling UC Benefits Customer Service at (800) 888-8267.

There are instances where denial of coverage is based on a determination that an individual did not meet the eligibility requirements of the University’s GIRs. That is, benefits are denied because the individual is not eligible to participate in a plan, did not enroll in a timely fashion, did not properly complete the enrollment process, was enrolled in error, etc. In these instances, a separate and distinct appeal process is available as described below. This process is not an alternative to any carrier appeal process nor is it the next level of appeal if the carrier’s process has already been exhausted. It is strictly intended to address denials of health and welfare coverage (including medical, dental, vision, legal, life, disability, flexible spending accounts and COBRA) based on plan eligibility under the University’s GIRs.

A claimant with an eligibility issue must submit a request for coverage, which must be made in accordance with procedures established under the GIRsPDF. No decision on the appeal will be made until an individual has submitted a written request for coverage and has provided pertinent information regarding the request as described below.

First Level of Appeal

If the UCPath Center denies a request for health and welfare benefits coverage, UCPath staff will provide the Eligibility Appeal Form for Health & Welfare Benefits Plans (UBEN 177)PDF and advise the employee that they can pursue an appeal directly with the UC Office of the President Appeals Committee (for Health & Welfare Benefits). The claimant or the claimant’s authorized representative can submit this form to officially request an independent review of the claim for eligibility under the GIRs. The UBEN 177 form must be submitted within 60 days of the written notice of the denial.

For most efficient processing, send the completed Eligibility Appeal Form for Health & Welfare Benefits Plans (UBEN 177)PDF via email to: HealthAndWelfareBenefitsAppeal-L@ucop.edu

Alternatively, the completed appeal form may be mailed to the address below. Please note that forms submitted by postal mail will take additional time to process.

Executive Director, Benefit Programs and Strategy
Human Resources, Health & Welfare Plan Administration
University of California
1111 Franklin St.
Oakland, CA 94607

The Eligibility Appeal Form for Health & Welfare Benefits Plans (UBEN 177)PDF is designed to:

1. Request a review of the UCPath Center’s denial of the claim (within 60 days of the written notice of the denial),
2. Set forth all of the reasons and supporting facts and documentation upon which the request for review is based; and
3. Include any issues or comments that the claimant deems relevant to the appeal.

Each appeal and any related written materials submitted by the claimant will receive a full and fair review within 60 days after the Executive Director’s receipt of the request for review unless the Executive Director determines that circumstances require a longer period for review, which may include time to review additional information or documents reasonably requested from the claimant, the carrier, the campus/laboratory location, the provider, or other relevant party. If additional time for review is needed, the claimant will be notified in writing of the need, and the reason, for the extended review period.

If the written notice includes a request that the claimant provide additional information or documents, the claimant must submit such information or documents within 30 days after receipt of the notice. If the claimant and/or any other relevant party has been asked for additional information or documents, written notice of the Executive Director’s decision shall be given within 60 days of receipt of all such information or documents. If the appeal is denied, the Executive Director’s written notice of the decision to the claimant shall set forth the specific reasons for such denial and any specific references on which the decision is based.

Second Level of Appeal

If the Executive Director sustained the decision to deny the claim, the claimant may ask the Plan Administrator to review the decision by submitting a written statement of appeal to the Vice President, Human Resources, of the University of California within 60 days after receiving a written notice of denial from the Executive Director. The procedures and requirements set forth above for the first level of appeal should be followed.

A second level appeal should be directed to:

Vice President, Human Resources
Attention: Health and Welfare Plan Appeals
University of California
1111 Franklin St.
Oakland, CA 94607

The decision of the Vice President, Human Resources regarding eligibility shall be final and conclusive upon all persons. With the Vice President’s decision, the claimant will have exhausted all administrative remedies under the plan. If after exhausting these administrative claims procedures, the claimant still believes that eligibility for coverage has been improperly denied, the claimant has the right to initiate legal proceedings.