MMC Benefits Handbook
Claim for Reimbursement Denials and Appeals
If Your Claim for Reimbursement Is Denied
If a claim for reimbursement of Eligible Healthcare Expenses is denied in part or in whole, you may call Mercer Marketplace Retiree at +1 800 553 4958 before requesting a formal appeal. If Mercer Marketplace Retiree cannot resolve the issue to your satisfaction over the phone, you have the right to file a formal appeal as described below.
How to Appeal a Denied Claim for Reimbursement
If you wish to appeal a denied claim for reimbursement, you or your authorized representative must submit your appeal in writing within 180 days of receiving the denial. This written communication should include:
  • the patient's name;
  • the provider's name;
  • the date of medical service or expense;
  • the reason you disagree with the denial; and
  • any documentation or other written information to support your request.
If you wish to request a formal appeal of a denied claim for reimbursement, you should call + 1 800 553 4958 to obtain Mercer Marketplace Retiree's address where the appeal should be sent.
Review of an Appeal for Reimbursement
Mercer Marketplace Retiree will conduct a full and fair review of your appeal for reimbursement. The appeal may be reviewed by an appropriate individual(s) who did not make the initial benefit determination.
Once the review is complete, if Mercer Marketplace Retiree upholds the denial, you will receive a written explanation of the reasons and facts relating to the denial.
If your claim for reimbursement continues to be denied or you do not receive a timely decision, in limited circumstances you may be able to request Mercer Marketplace Retiree to initiate an external review of your claim by an independent third party who will review the denial and issue a final decision.
Note: Upon written request and free of charge, any eligible persons may examine documents relevant to their claim and/or appeals for reimbursement and submit opinions and comments. Mercer Marketplace Retiree will review all claims for reimbursement in accordance with the rules established by the US Department of Labor. Mercer Marketplace Retiree's decision will be final and binding.
The table below describes the time frames which you and Mercer Marketplace Retiree are required to follow:
Claim Denials and Appeals for Reimbursement
Type of Claim or Appeal for Reimbursement
Timing
If your claim for reimbursement is incomplete, Mercer Marketplace Retiree must notify you within:
30 days
You must then provide completed claim for reimbursement information Mercer Marketplace Retiree within:
45 days after receiving an extension notice*
If the Mercer Marketplace Retiree denies your initial claim for reimbursement, they must notify you of the denial:
  • if the initial claim for reimbursement is complete, within:
30 days
  • after receiving the completed claim for reimbursement (if the initial claim for reimbursement is incomplete), within:
30 days
You must appeal the claim for reimbursement denial no later than:
180 days after receiving the denial
Mercer Marketplace Retiree must notify you of the appeal decision within:
60 days after receiving the first level appeal
* Mercer Marketplace Retiree may require a one-time extension of no more than 15 days only if more time is needed due to circumstances beyond their control.
Claims Concerning Eligibility and Enrollment
If your claim concerns whether or not you or a family member is eligible to participate in the RRA, you may file a claim with the Plan Administrator. The claim should be in writing and specify the circumstances under which you have been determined to be ineligible to participate, why you believe you should be eligible to participate and include any mitigating factors, documents, records or other information that may be pertinent and should be sent to the Plan Administrator. You may file a written appeal of an adverse claim determination with the Plan Administrator. A written appeal of a denied claim should include all the information necessary for the original claim as well as any additional information you would like the plan to consider. Please see the Administrative Information section of the Benefits Handbook at https://connect.mmc.com for more information.