Authorized Representative
A claimant may appoint an “authorized representative” to act on his or her behalf solely with respect to an appeal of an adverse benefit determination or an inquiry concerning an adverse benefit decision. To appoint an
authorized representative, a claimant must complete a form that can be obtained from the Claims Administrator. However, in connection with an Urgent Care Claim, the Claims Administrator will permit a health care professional with knowledge of the claimant's medical condition to act as the claimant's authorized representative without completion of this form. Once an authorized representative is appointed, all future communication from the Claims Administrator will be made with the representative rather than the claimant, unless the claimant provides specific written direction otherwise.
An assignment for purposes of payment (e.g., to a health care professional) does not constitute an appointment of an authorized representative under these claims procedures. Any reference in these claims procedures to
claimant is intended to include the authorized representative of such claimant.
A claimant may not assign to any other person or entity his or her right to legally challenge any decision, action, or inaction of the Claims Administrator.
Office of Student Health Benefits Review Process for Eligibility, Enrollment, or Other Administrative Issues
If you are disputing a determination concerning an eligibility, enrollment, or other administrative issue, you may also contact the Office of Student Health Benefits (OSHB) directly, by telephone (612-624-0627 or 1-800-232- 9017), fax (612-626-5183), or by mail to Office of Student Health Benefits, University of Minnesota, 410 Church Street S.E., N323, Minneapolis, MN 55455. You must contact the Office of Student Health Benefits within 90 days of the date that the eligibility, enrollment, or other administrative issue first became apparent.
The OSHB representative will first assist you in trying to resolve the concern on an informal basis. If you are unable to resolve your concern informally, a written request for review, including the concerns you have about your eligibility, enrollment, or other administrative issue, plus supporting documentation, can be submitted. You will receive a telephone or written response from the OSHB as soon as possible, but not later than 30 days following the University’s receipt of your request for review.
Office of Student Health Benefits Committee Review of Coverage Denials
If your pre-authorization of claim under the plan is wholly or partially denied by the Plan Administrator or if you do not agree with the response from the University of Minnesota, Office of Student Health Benefits, you may request a review by the Office of Student Health Benefits Review Committee.
Your request must be in writing and be received by fax (612-626-0808) or by mail at Office of Student Health Benefits, University of Minnesota, 410 Church Street S.E., N323, Minneapolis, MN, 55455, within 60 days of the denial of your coverage. A written decision will be sent to you from the Office of Student Health Benefits Review Committee within 30 days of the receipt of your request for review.
Office of Student Health Benefits Director Final Review
Within 60 days of receiving a denial of coverage from the Office of Student Health Benefits Review Committee, you may submit a final appeal to the Office of Student Health Benefits Director. You should submit your written request for appeal to Office of Student Health Benefits, University of Minnesota, 410 Church Street S.E., N323,
Claims Payment
When a claimant uses In-Network or Out-of-Network Participating Providers, the Student Health Benefit Plan pays the provider. When a claimant uses a Nonparticipating Provider, the Student Health Benefit Plan pays the
claimant. A claimant may not assign his or her benefits to a Nonparticipating Provider, except when parents are divorced. In that case, the custodial parent may request, in writing, that the Student Health Benefit Plan pay a Nonparticipating Provider for covered services for a child. When the Student Health Benefit Plan pays the provider at the request of the custodial parent, the Student Health Benefit Plan has satisfied its payment obligation. This provision may be waived for ambulance providers in Minnesota and certain institutional and medical/surgical providers outside the state of Minnesota at the discretion of the Claims Administrator. The Student Health Benefit Plan does not pay claims to providers or to employees for services received in countries that are sanctioned by the United States Department of Treasury’s Office of Foreign Assets Control (OFAC), except for medical emergency services when payment of such services is authorized by OFAC.
Countries currently sanctioned by OFAC include Cuba, Iran, and Syria. OFAC may add or remove countries from time to time.
No Third Party Beneficiaries
The Student Health Benefit Plan benefits described in this Summary Plan Description are intended solely for the benefit of you and your covered dependents. No person who is not a Student Health Benefit Plan participant or dependent of a Student Health Benefit Plan participant may bring a legal or equitable claim or cause of action pursuant to this Summary Plan Description as an intended or third party beneficiary or assignee hereof. Release of Records
Claimants agree to allow all health care providers to give the Claims Administrator needed information about the care that they provide to them. The Claims Administrator may need this information to process claims, conduct utilization review, care management, quality improvement activities, reimbursement and subrogation, and for other health plan activities as permitted by law. If a provider requires special authorization for release of records, claimants agree to provide this authorization. A claimant’s failure to provide authorization or requested information may result in denial of the claimant’s claim.
Right of Examination
The Claims Administrator and the Plan Administrator each have the right to ask a claimant to be examined by a provider during the review of any claim. The Student Health Benefit Plan pays for the exam whenever either the Claims Administrator or the Plan Administrator requests the exam. A claimant’s failure to comply with this request may result in denial of the claimant’s claim.