DENIAL CLINIC

REASON CODES & EXPLANATIONS

Below are the reasons presented as to why a claim/charge may be denied reimbursement or for debit substantiation. Under each denial reason code, you will find the explanation and what action may be taken to resubmit/resolve the issue.

All claims received by O.C.A. Benefit Services, whether associated with a Health Reimbursement Arrangement (HRA) or Flexible Spending Account (FSA), are subject to our adjudication standards that take into account the Company’s legal documents (Summary Plan Description), in addition to current compliance regulations under Section 213(d) of the IRS.

	*Ineligible Expense Submitted (FSA):* Your claim has been denied because the expense is not eligible for reimbursement under your Flexible Spending Account. Reimbursable expenses are limited and defined by the Internal Revenue Code Section 125.
	*Action/Resolution:* The IRS publishes a list of items (Publication 502) they deem reimbursable under a Flexible Spending Account. The expense(s) submitted were identified as non-eligible expenses in accordance with Section 213(d) of the IRS code. No action is required. (To view the list of eligible expenses visit our website at www.oca125.com and click the eligible FSA link.)
	*Copy of Substantiation is not readable:* Please resubmit a clear copy of the Substantiation. Your expense cannot be reimbursed until you resend or fax a copy.
	*Action/Resolution:* This simply indicates that the supporting documentation is unreadable or in cases of FSA documentation, there was not enough information to identify the item in question. To resolve, the individual should resubmit including original documentation or ensuring clear copies. In cases where an FSA expense is in question, please feel free to include box tops to assist our Claim Processors in identifying whether the item is an eligible expense in accordance with IRS guidelines.
	*Not a FSA participant:* Your Claim was denied because it appears that you are not a Section 125 Flexible Spending Account participant. According to our records you are not enrolled in this plan. If you believe we are in error, please contact your HR Department or contact us using the information listed below.
	*Action/Resolution:* This indicates that O.C.A. Benefit Services’ system does not reflect this individual as being enrolled as an FSA participant. If an individual is currently contributing toward an FSA account through payroll deductions, they should contact their HR Representative to have this error corrected in our system. If not, no action is required.
	*Year-to-Date Claims Exceed by this Claim:* Even though the claim expense submitted is eligible, your claim cannot be reimbursed because Year-to-Date submitted Claims Exceed the annual election.
	*Action/Resolution:* This is informing an individual that the amount being requested for reimbursed is above the dollar threshold (or annual limit) for the year. Since the account has exhausted funds, there is no reimbursement and no action is required.
	*Signature Required:* The claim form you submitted was not signed where it states "Employee Signature." Please resubmit the claim form with your signature in order for reimbursement to be released.
	*Action/Resolution:* Due to legal restrictions and for the employee’s protection, O.C.A. is unable to process claims unless the claim form is signed and dated by the employee. Once the form has been signed and dated, it should be resent to O.C.A. for processing.
	*Prior to Inception of Plan:* Your claim has been denied because it appeared the date the service was rendered for this expense incurred prior to the inception of the plan.
	*Action/Resolution:* Since claims must be incurred during the plan year, this is indicating that the date of service (or date the service was incurred) was prior to the date the plan started and therefore, the claim is ineligible. No action required.
	*3rd Party Documentation:* Your claim has been denied because the third-party documentation included did not provide substantiation as required by the IRS. Please note that the third-party documentation should state the following: date services were rendered, who the services were rendered for, who rendered the services, and lastly the amount paid for said services.
	*Action/Resolution:* This is to inform an individual that the supporting documentation received had one of the above mentioned pieces of information missing that precluded O.C.A. from processing the reimbursement. Once additional documentation containing the missing information has been obtained, resubmit to O.C.A. for processing.
	*Duplicate Claims:* Your claim has been denied because it appeared that you were previously reimbursed for this expense on an earlier date. Please log onto www.myrsc.com or contact O.C.A. directly for further details.
	*Action/Resolution:* This will inform an individual whenever a claim had been previously submitted to O.C.A. and either a reimbursement was released or a debit transaction was substantiated. In cases where there was a reimbursement – the check number, amount of check and date the check was issued will be included. No action required.
	*Not a 105 participant:* Your claim was denied because it appeared that you are not a Section 105 Medical Reimbursement Plan participant. According to our records you are not enrolled in this plan. If you believe we are in error, please contact your HR Department or contact us using the information listed below.
	*Action/Resolution:* This indicates that O.C.A. Benefit Services’ system does not reflect this individual as being enrolled as an FSA participant. If an individual is currently contributing toward an FSA account through payroll deductions, they should contact their HR Representative to have this error corrected in our system. If not, no action is required.
	*Stockpiling:* The reason why a portion of your claim has been denied was due to "stockpiling" regulations. Under IRS Guidelines, an individual may submit a maximum limit of 2 of any particular item purchased on the same day under a Flexible Spending Account.
	*Action/Resolution:* In accordance with IRS regulations, an individual may submit for reimbursement a maximum limit of “2” of any particular item that was PURCHASED on the same day. Therefore, if supporting documentation indicates that there are 3 or more of any particular item purchased on the same day, the individual will be reimbursed for only 2.
	Expense incurred after Termination date: Your claim has been denied because it appeared that the date of service for this expense incurred after the coverage termination date.
	*Action/Resolution:* Since the date(s) of service must be incurred while the individual was actively participating in the plan, this states that the service date(s) took place after the termination date O.C.A. was provided. If an individual feels that a claim was denied in error as a result of a termination date discrepancy, they need to contact the HR Department for clarification.
	*Details Summary Page of EOB:* Your claim has been denied because your company's plan will only accept an Explanation of Benefits from the insurance carrier associated with this expense. When you obtain of Details Summary Page of the Explanation of Benefits, please mail or fax it to our office.
	*Action/Resolution:* The supporting documentation to process the claim in accordance with the Plan Documents requires O.C.A. has an Explanation of Benefits from the insurance carrier. Specifically, the “Details Summary Page” of the Explanation of Benefits state the following information: date of service, provider type of service, billed amount, allowed amount, coins/co-pay amount, deductible amount, carrier payment amount, not covered amount, insurance paid amount, message code, and subscriber responsibility. Individuals should resubmit the requested information for reimbursement or debit substantiation to be considered.
	*Duplicate Submission (Same Claim Form):* The reason why a portion of your claim was denied is because it appears that part of the expense requested for reimbursement is a duplication of another expense on this same claim submission.
	Action/Resolution: This is informing an individual that a portion of their claim was denied due to that portion being a duplicate of another claim on the same submission. No action is required.
	*HRA Ineligible Expense:* Your claim was denied under your company's HRA plan because it was not applicable toward any eligible expense as described in your Summary Plan Description as indicated by your Explanation of Benefits.
	*Action/Resolution:* This denial code is informing an individual that the expense requested for reimbursement is not a covered expense designated by the plan documents. For example, maybe the plan does not reimburse for coinsurance or out-of-network expenses. We recommend that individuals refer to their Summary Plan Description to see what expenses are covered by their company’s HRA plan. Should an individual need clarification, they may always contact O.C.A. directly.
	*Requested Info on Claim Form:* Your recent submission for reimbursement was denied because it appears that the claim form had not been filled out indicating the expense(s) and amount(s) to be reimbursed.
	*Action/Resolution:* For legal compliance and quality assurance, claim forms received with expense information missing are denied. Once an individual completes their claim form, it should be resubmitted for reimbursement or debit substantiation.
	*Vitamins:* Your claim has been denied because the expense appears to be an over-the-counter vitamin. This item is not eligible for reimbursement under your Flexible Spending Account unless prescribed by a physician to treat a specific medical condition. For reconsideration of payment, a prescription from your physician which outlines the details surrounding the medical condition necessitating the need for the vitamins would be required.
	*Action/Resolution:* In accordance with IRS regulations, under an FSA plan in order for vitamins to be considered an eligible expense – an individual would need to include a note from the prescribing doctor of the vitamins stating the specific medical condition being treated. As an important reminder, the note only needs to be submitted once for a particular vitamin and is kept on file for the duration of the plan year. The note expires at the end of the plan year and new doctor’s note would need to be submitted the following year. Once note has been obtained, individual should resubmit for reimbursement.
	*HRA Ineligible Expense w/RX:* Your claim was denied under your company's HRA plan because it was not applicable toward any eligible expense as described in your Summary Plan Description as indicated by your Explanation of Benefits or a valid RX Stub.
	*Action/Resolution:* This denial code is informing an individual that the expense requested for reimbursement is not a covered expense designated by the plan documents and that would include prescriptions. For example, maybe the plan does not reimburse for coinsurance or out-of-network expenses. We recommend that individuals refer to their Summary Plan Description to see what expenses are covered by their company’s HRA plan. Should an individual need clarification, they may always contact O.C.A. directly.
	*EOB Required:* Your claim has been denied because your company's plan requires an Explanation of Benefits from your insurance carrier associated with this expense in order to release payment.
	*Action/Resolution:* In order to process the claim as required by the plan documents, O.C.A. would need the Details Summary Page of the Explanation of Benefits an individual would receive from their insurance carrier. This shows the services rendered and how those services were applied to insurance (i.e. deductible, coinsurance, etc.) and provides the information necessary to ensure reimbursements rendered meet with the company’s plan design. Once an individual obtains their EOB, their claim should be resubmitted for reimbursement or debit substantiation.
	*Prior year submitted after 180 days (HRA):* Your claim has been denied because it appeared that this expense was incurred during the Plan Year for "2007." Since our office did not receive the request form for this expense on or before the plan year deadline of 180 days from close of the plan year, as stated in your Summary Plan Description, it was denied.
	*Action/Resolution:* If the company’s Summary Plan Description allows for a 180 “grace” period on the HRA plan. This allows an individual to *submit* claims 180 days beyond the plan’s closing date. The expense still must have been incurred within the active plan year. However, this is informing the individual that the claim was received after that deadline.
	*Prior year submitted after 90 days (3/31):* Your claim has been denied because it appeared that this expense was incurred during the Plan Year for "2007." Since our office did not receive the request form for this expense on or before the plan year deadline of 90 days from close of the plan year, as stated in your Summary Plan Description, it was denied.
	*Action/Resolution:* This is informing an individual that we received the claim beyond the mandated deadline for either the “grace” or “run-out” periods pertaining to HRA and FSA plans, thus making the claim ineligible. A “grace” period allows individuals to *submit* claims incurred within the current plan year, 90 days beyond the plan year’s closing date. In other words, should the plan run from January 1^st through December 31^st, individuals have 90 days beyond December 31^st to submit claims that they incurred (date of service) during the plan year. A “run-out” period relates solely to FSA participants. This allows individuals to not only to submit expenses beyond the plan year’s closing date, but also to incur expenses. Should a “run-out” period apply, then individuals have until March 15^th of the following year to *incur* expenses, but only until March 31^st (March 30^th in cases when it is a leap year) to *submit* the expense. When reimbursements are made for those claims submitted specifically for the “grace” and “run-out” periods, the funds are pulled from the previous year’s remaining balance. Please note: We recommend that all individuals refer to their company’s Summary Plan Description to know what their company approves. In order for claims to be considered for reimbursement in accordance with plan documents and IRS regulations, O.C.A. must to receive the claim by midnight if sent via fax or email of the 90^th day. If sent via USPS, the envelope must be postmarked by the 90^th day.