Claims Process

Claims Procedures

You may access EAP benefits by contacting CIGNA Behavioral Health directly; you are not required to file a claim for EAP services. If you are unhappy with the service that you receive or you are unable to obtain service, you may complain directly to CIGNA Behavioral Health. CIGNA Behavioral Health is the Administrator for EAP benefits. For information about filing an appeal, see the claims information regarding EAP benefits and the Appeal Procedures in the 'Plan Information section of the SAIC SPD document.

Employee Assistance Program Claim Determinations

Making a Claim for EAP Services

CIGNA Behavioral Health will generally make a determination on your request for EAP services and inform you of its determination in your initial telephone call to request services.

If CIGNA Behavioral Health cannot decide while on the initial call, CIGNA Behavioral Health will decide within five (5) calendar days of your request for services or of notice to CIGNA Behavioral Health of a circumstance that affects the availability of further EAP services. CIGNA Behavioral Health will inform you by telephone of its determination within one (1) business day after it decides.

If you are receiving an ongoing course of EAP counseling, CIGNA Behavioral Health will notify you in advance if it intends to terminate or reduce the number of EAP sessions that can be provided, so that you will have an opportunity to appeal the decision before the termination or reduction takes effect.

What is a Claim?

A Claim is a request for benefits made in accordance with the Plan's procedures. A Claim may be either a request for EAP services or a request for reimbursement of the cost of EAP counseling.

What is Urgent Care?

Urgent care means care needed to avoid serious jeopardy to your life or health or to regain maximum function (or required to avoid severe pain), as determined by CIGNA Behavioral Health or your treating physician.

Because CIGNA Behavioral Health pays all EAP providers directly, you should not make any payment to a provider for EAP services. In the event that you mistakenly pay a provider for EAP services, CIGNA Behavioral Health will make a determination on your request for reimbursement within 15 days after receipt of the Claim (if EAP services have not yet been received) or with 30 days after receipt of the Claim (if the EAP services have already been received).

Adverse Determinations of a Claim for EAP Benefits

If a Claim for EAP benefits is wholly or partially denied, and you authorize written communication to you, CIGNA Behavioral Health will provide written notice of the denial to you or your Authorized Representative.

This notice of the decision will:

• Give the specific reason or reasons for the denial decision
• Identify Plan provisions on which the decision is based
• Describe any additional material or information necessary for an appeal review and an explanation of why it is necessary
• Explain the review procedure, including time limits for appealing the decision and to sue in federal court
• Identify your right to receive, free of charge, upon your request, any internal rule, guidelines, protocol or similar criterion relied on in making the decision
• Identify your right to receive, free of charge, upon your request, an explanation of the clinical judgment on which the decision is based (if the denial is based on exclusion of experimental treatment services or because EAP services are not clinically appropriate)

If you do not authorize written notice, CIGNA Behavioral Health will furnish this information to you or your Authorized Representative by telephone.

Who is your Authorized Representative?

An Authorized Representative is a person you authorize, in writing, to act on your behalf, or a person given authority by court order to request treatment or submit claims on your behalf.

Appeals of Adverse Determinations of Claims for EAP Benefits

If you believe that your Claim for EAP benefits was denied in error, you may appeal the decision. Your appeal must be submitted in writing to CIGNA Behavioral Health within 180 days following your receipt of a denial notice.

Your appeal should state the reasons why you feel your Claim for EAP benefits is valid and include any additional documentation that you feel supports your Claim for EAP benefits. You can also include any additional questions or comments. You may submit written comments, documents, records and other information relating to your appeal, whether or not the comments, documents, records or information were submitted in connection with the initial Claim for EAP benefits. On your request, CIGNA Behavioral Health will make relevant documents available to you.

The review of the initial decision will consider all new information, whether or not it was presented or available for the initial decision. The person who reviews and decides the appeal will be different from the person(s) who originally denied your Claim for EAP benefits and will not report directly to the original decision maker or prior reviewer.

You or your Authorized Representative will be notified of the appeal decision within the following time frames:

If the case involves an adverse determination on a request for EAP services or a pre-service adverse determination relating to reimbursement, within thirty (30) days of CIGNA Behavioral Health's receipt of the request for appeal;

If the case involves a post-service adverse determination relating to reimbursement, within sixty (60) days of CIGNA Behavioral Health's receipt of the request for appeal.

Appeal Decisions

If you authorize written communication, CIGNA Behavioral Health will give you or your Authorized Representative the decision on the appeal in writing. If the denial is upheld on the appeal, the notice will include the following information:

• The specific reason or reasons for the denial decision
• Identification of Plan provisions on which the decision is based
• Notice of your right to receive, free of charge, upon your request, any internal rule, guidelines, protocol or similar criterion relied on in making the decision;
• Notice of your right to receive, free of charge, upon your request, an explanation of the clinical judgment on which the decision is based (if the denial is based on exclusion of experimental treatment services or because EAP services are not clinically appropriate)
• Notice of your right to receive, free of charge, upon your request, reasonable access to, and copies of, all documents, records and other information relevant to the appeal
• Notice of your right to bring a civil lawsuit under ERISA Section 502(a)

If you do not authorize written notification, CIGNA Behavioral Health will furnish this information to you or your Authorized Representative by telephone.

If you do not agree with the final decision of CIGNA Behavioral Health, you may bring a lawsuit in federal district court. You cannot bring legal action unless your Claim has been reviewed and denied by CIGNA Behavioral Health.