IMPERATIVE-ACTION REQUIRED

Dear Director of :

This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to reimburse health services as required by Federal law.

Our investigation has concluded the following:

As you know, federal law requires to pay this claim within 30 days under 29 CFR §2560.503-1(f)(2)(iii)(B), which states:

(B) Post-service claims. In the case of a post-service claim, the plan administrator shall notify the claimant, in accordance with paragraph (g) of this section, of the plan’s adverse benefit determination within a reasonable period of time, but not later than 30 days after receipt of the claim. This period may be extended one time by the plan for up to 15 days, provided that the plan administrator both determines that such an extension is necessary due to matters beyond the control of the plan and notifies the claimant, prior to the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which the plan expects to render a decision. If such an extension is necessary due to a failure of the claimant to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the claimant shall be afforded at least 45 days from receipt of the notice within which to provide the specified information. (Emphasis added.)

Under these circumstances, it is your obligation to ensure the continuous provision of quality healthcare to your enrollees, and comply with the prompt payment provisions of Sec. 5260.503-1 in order to indemnify the beneficiary enrollee for payment of any fees that are the legal obligation of the health plan for services furnished by providers to its enrollees.

We hereby demand immediate payment of the above referenced claim(s) plus interest pursuant to to 31 U.S.C §3902 (a-c). Should you fail to remit payment to the undersigned within ten (10) days, be advised that we may draft a formal complaint to the Department of Labor (DOL) to ensure our rights under federal and state law are preserved.

Please make any further action on our part unnecessary, by remitting payment in full immediately.

 

Sincerely,