Claiming Benefits

Plan Administration

Claiming Benefits

This section provides a comprehensive overview of the benefits claims appeal process for the plans under the JPMorgan Chase Benefits Program that are subject to the Employee Retirement Income Security Act of 1974 (ERISA). It includes detailed information about what happens at each step in the process and includes important timing requirements. This section also includes information about each plan's "fiduciary" and contact information. See "About Plan Fiduciaries" and "Contacting the Claims Administrators."

If you have filed a claim for benefits and your claim is denied, you have the right to appeal the decision.

What Qualifies as a "Denied Benefit?"

A "denied benefit" is any denial, reduction, or termination of a benefit, or a failure to provide or make a payment, in whole or in part, for a benefit. In addition, a benefit may be denied if you didn't include enough information with your initial claim.

JPMorgan Chase is not involved in deciding appeals for any denied benefit claim under the:

Medical Plan Health Maintenance Organization (HMO) Option and Exclusive Provider Organization (EPO) Option,

Dental Plan Dental Maintenance Organization (DMO) Option and Dental Health Maintenance Organization (DHMO) Option;

Vision Plan;

Health Care Spending Account, Child/Elder Care Spending Account, and Transportation Spending Accounts;

Long-Term Disability Plan;

Life and Accident Insurance Plans;

Group Legal Services Plan;

Long-Term Care Insurance Plan; and

Employee Assistance Program.

All fiduciary responsibility and decisions regarding a claim for a denied benefit under these plans will rest solely with the applicable claims administrator.

However, with respect to appeals denied by a claims administrator under the following self-insured options, these options permit (but do not require) voluntary appeals to the JPMorgan Chase Employee Benefits Appeals Committee:

Medical Plan Point-of-Service (POS), Preferred Provider Organization (PPO), and Traditional Indemnity Options (including the Prescription Drug Plan), Medicare Traditional Indemnity High and Low Options, and

Dental Plan Preferred Dentist Program (PDP) and Traditional Indemnity Options.

The Plan Administrator has final fiduciary responsibility for all appeals under the Retirement Plan and 401(k) Savings Plan, although the JPMorgan Chase Employee Benefits Appeals Committee may make a recommendation to the Plan Administrator about a denied claim.

Steps in the Benefits Claims Appeal Process

Step 1: Filing Your Initial Claim for Benefits

In general, when you file a claim for benefits, it is paid according to the provisions of the specific benefits plan. There are different time requirements for different plans, as outlined in the following table.


Plan	Timing for Filing Your Initial Claim
Medical,* Prescription Drug, Dental, and Vision Plans	No later than December 31 of the year following the year in which services were provided. Please contact your claim's administrator for more information. (Please see "Contacting the Claims Administrators.")
Health Care Spending Account	April 30 of the year following the year in which the expense is incurred. Expenses incurred during the two and a half month grace period (January – March 15 of the following year) must be filed by April 30 of the current year to be applied to the prior year's account balance.
Child/Elder Care Spending Account	April 30 of the year following the year in which the expense is incurred.
Transportation Spending Accounts	"Pay Me Back" claims under the Parking Account must be filed within 180 days from the date the expense was incurred.
Long-Term Disability Plan	No time limit. However, you should file your claim as soon as possible.
Life and Accident Insurance Plans	No time limit. However, you should file your claim as soon as possible.
Long-Term Care Insurance Plan	You must submit written proof of claim no later than 90 days after the end of the calendar year in which the expenses were incurred.
Group Legal Services Plan	No later than December 31 of the year following the year in which services were provided.
Employee Assistance Program	90 days from date of service
Retirement Plan	Generally, 60 days before you want to begin receiving eligible benefit payments.
401(k) Savings Plan	Before you want to begin receiving eligible benefit payments.

*Please Note: Generally, in-network PPO/POS, HMO, EPO, DMO, and Vision claims filing is performed by the physician.

Step 2: Receiving Notification from the Claims Administrator/Plan Administrator If an Initial Claim for Benefits Is Denied

If an initial claim for benefits is denied, the claims administrator or Plan Administrator will notify you within a "reasonable" period of time, not to exceed the time frames outlined in the table below.

Under certain circumstances, the claims administrator or Plan Administrator is allowed an extension of time to notify you of a denied benefit. Please Note: If an extension is necessary because you did not submit necessary information needed to process your health care claim (except in the case of urgent care where the life of a claimant could be jeopardized) or disability claim, the timing for making a decision about your claim is stopped from the date the claims administrator sends you an extension notification until the date that you respond to the request for additional information. You generally have 45 days from the date you receive the extension notice to send the requested information to the claims administrator.


Plan/Option	Timing for Notification of a Denial of Benefits Claim
Medical Plan, Prescription Drug Plan, and Dental Plan	72 hours for claims involving urgent care, where the life of a claimant could be jeopardized (may be oral, with written confirmation within three days) Please Note: You must be notified if your claim is approved or denied. 15 days for pre-service claims, where approval is required before receiving benefits, plus one 15-day extension due to matters beyond the plan's control. 30 days for post-service claims, where the claim is made after care is received, plus one 15-day extension due to matters beyond the plan's control.
Vision Plan	30 days, plus one 15-day extension for matters beyond the plan's control.
Health Care Spending Account	15 days
Child/Elder Care Spending Account	15 days
Transportation Spending Accounts	30 days
Long-Term Disability Plan	45 days, plus two 30-day extensions due to matters beyond the plan's control.
Life and Accident Insurance Plans	45 days, plus two 30-day extensions for matters beyond the plan's control.
Long-Term Care Insurance Plan	Within 10 working days after claims administrator has received all information needed to make a determination for claim.
Group Legal Services Plan	30 days
Employee Assistance Program	72 hours for claims involving urgent care, where the life of a claimant could be jeopardized (may be oral, with written confirmation within three days) Please Note: You must be notified if your claim is approved or denied. 15 days for pre-service claims, where approval is required before receiving benefits, plus one 15-day extension due to matters beyond the plan's control. 30 days for post-service claims, where the claim is made after care is received, plus one 15-day extension due to matters beyond the plan's control.
Retirement and 401(k) Savings Plans	90 days, plus one 90-day extension for matters beyond the plan's control.

Please Note: Concurrent care claims are claims for which the plan has previously approved a course of treatment over a period of time or for a specific number of treatments, and the plan later reduces or terminates coverage for those treatments. Concurrent care claims may fall under any of the other three categories, depending on when the appeal is made. However, the plan must give you sufficient advance notice to appeal the claim before a concurrent care decision takes effect.

The Explanation You'll Receive from the Claims Administrator/Plan Administrator in the Case of a Denied Benefit

If your initial claim is denied, the claims administrator or Plan Administrator is legally required to provide an explanation for the denial, which will include the following:

The specific reason(s) for the denial.

References to the specific plan provisions on which the denial is based.

A description of any additional material or information needed to process your claim and an explanation of why that material or information is necessary.

A description of the plan's appeal procedures and time limits, including a statement of your right to bring a civil action under ERISA after, and if, your appeal is denied.

If your claim is for health care benefits, the explanation must also include:

Any internal rule, guideline, protocol, or other similar criterion relied upon in making the benefit denial, or a statement that a copy of this information will be provided free of charge upon request.

If the benefit was denied based on a medical necessity, experimental treatment, or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the denial applying the terms of the plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request.

Step 3: Filing an Appeal to the Claims Administrator/Plan Administrator If an Initial Claim for Benefits Is Denied

If your initial claim for benefits is denied, you — or your authorized representative — may file an appeal of the decision with the applicable claims administrator or Plan Administrator within the timeframes indicated below:


Plan/Option	Timing for Filing an Appeal of a Denial of Benefits Claim
Medical Plan, Prescription Drug Plan, and Dental Plan	180 days
Vision Plan	180 days
Health Care Spending Account	180 days
Child/Elder Care Spending Account	180 days
Transportation Spending Accounts	90 days
Long-Term Disability Plan	180 days
Life and Accident Insurance Plans	180 days
Long-Term Care Insurance Plan	60 days
Group Legal Services Plan	60 days
Employee Assistance Program	180 days
Retirement and 401(k) Savings Plans	60 days

An Important Reminder

The Child/Elder Care Spending Account, Transportation Spending Accounts, Excess Retirement Plan, Employee Stock Purchase Plan, and the Bank One Supplemental Savings and Investment Plan (SSIP) are not subject to the provisions of ERISA.

In your appeal, you have the right to:

Submit written comments, documents, records, and other information relating to your claim.

Request, free of charge, reasonable access to, and copies of, all documents, records, and other information that:

Was relied upon in denying the benefit.

Was submitted, considered, or generated in the course of denying the benefit, regardless of whether it was relied on in making this decision.

Demonstrates compliance with the administrative processes and safeguards required in denying the benefit.

For health care claims only: Constitutes a policy statement or plan guideline concerning the denied benefit regardless of whether the policy or guideline was relied on in denying the benefit.

A review of your claim that takes into account all comments, documents, records, and other information submitted or considered in the initial decision to deny the benefit.

If your appeal is for health care benefits, you also have the right to receive:

A review that does not defer to the initial benefit denial and that is conducted by someone other than the person who made the denial or that person's subordinate.

For a denied benefit based on medical judgment (including whether a particular treatment, drug, or other item is experimental), a review in which the plan fiduciary/claims administrator consults with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment, and who was not consulted in connection with the initial benefits denial, nor the subordinate of this person.

The identification of medical or vocational experts whose advice was obtained in connection with denying the benefit, regardless of whether the advice was relied on in making this decision.

In the case of an urgent care claim where the life of a claimant could be jeopardized, an expedited review process in which:

You may submit a request (orally or in writing) for an expedited appeal of a denied benefit.

All necessary information, including the decision on your appeal, will be transmitted between the plan fiduciary/claims administrator and you by telephone, facsimile, or other available similarly prompt method.

Step 4: Receiving Notification from the Claims Administrator/Plan Administrator If Your Appeal Is Denied

If your appeal is subsequently denied, the claims administrator or Plan Administrator is legally required to notify you in writing of this decision within a "reasonable" period of time according to the time frames outlined in the table below.


Plan/Option	Timing for Notification of a Denied Benefits Appeal
Medical Plan, Prescription Drug Plan, and Dental Plan (all options)	72 hours for claims where the life of a claimant could be jeopardized (urgent care) 30 days where approval is required before receiving benefits (pre-service claims) 60 days where the claim is made after care is received (post-service claims)
Vision Plan	60 calendar days
Health Care Spending Account	30 days
Child/Elder Care Spending Account	30 days
Transportation Spending Accounts	30 days
Long-Term Disability Plan	45 days, plus one 45-day extension due to matters beyond the plan's control
Life and Accident Insurance Plans	45 days, plus one 45-day extension due to matters beyond the plan's control
Long-Term Care Insurance Plan	60 days
Group Legal Services Plan	60 days
Employee Assistance Program	72 hours for claims where the life of a claimant could be jeopardized (urgent care) 30 days where approval is required before receiving benefits (pre-service claims) 60 days where the claim is made after care is received (post-service claims)
Retirement and 401(k) Savings Plans	60 days of receipt of the appeal, plus one 60-day extension due to matters beyond the plan's control

Except in the case of health care claims, the claims administrator or the Plan Administrator is allowed to take an extension to notify you of a denied appeal under certain circumstances. If an extension is necessary, the claims administrator or Plan Administrator will notify you before the end of the original notification period. This notification will include the reason(s) for the extension and the date the claims administrator or the Plan Administrator expects to provide a decision on your appeal for the denied benefit. Please Note: If an extension is necessary because you did not submit enough information to decide your appeal, the time frame for decisions is stopped from the date the claims administrator or the Plan Administrator sends you an extension notification until the date that you respond to the request for additional information.

The Explanation You'll Receive from the Claims Administrator/Plan Administrator in the Case of a Denied Appeal

If an appeal is denied, the claims administrator or Plan Administrator is legally required to provide an explanation for the denial, which will include the following:

The specific reason(s) for the denial.

References to the specific plan provisions on which the denial is based.

A description of any additional material or information needed to process your appeal and an explanation of why that material or information is necessary.

A description of the plan's appeal procedures and time limits, including a statement of your right to bring a civil action under ERISA after, and if, your appeal is denied.

A statement that you're entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim.

A statement describing any voluntary appeal procedures offered by the plan and your right to obtain the information about such procedures, and a statement of your right to bring a civil action under ERISA.

If your appeal is for health care benefits, the explanation must also include:

A description of the expedited review process for urgent care claims where the life of the claimant could be jeopardized.

Other Options Available to You

If an initial claim for benefits and any follow-up appeal is denied (in whole or in part), you may file suit in a federal court. If you are successful, the court may order the defending person or organization to pay your related legal fees. If you lose, the court may order you to pay these fees (for example, if the court finds your claim frivolous). You may contact the Department of Labor or your state insurance regulatory agency for information about other available options.

Step 5: Filing a Final "Voluntary" Appeal

Voluntary appeals only apply to the following plans:

Medical Plan Preferred Provider Organization (PPO)/Point-of-Service (POS), Traditional Indemnity Options, Medicare Traditional Indemnity High and Low Options;

Prescription Drug Plan; and the

Dental Plan Preferred Dentist Program (PDP) or Traditional Indemnity Options.

In situations of a denied health care benefit under one of the plans listed above, you may request a "voluntary" appeal review from the JPMorgan Chase Employee Benefits Appeals Committee within 30 days after the final appeal with the applicable claims administrator has been exhausted. This voluntary appeal review will have no effect on your rights to challenge the initial decision in federal court under ERISA, and any statute of limitations does not continue to run during the period of any such voluntary appeal. In addition, no costs or fees will be imposed on you for requesting this appeal. The plan will not assert that you have failed to exhaust administrative remedies because you did not elect a voluntary appeal. Other information will be provided to you about the voluntary appeal process if your appeal is denied and the voluntary appeal process is available to you.

The claim must be for an amount greater than $500.

Please Note: Voluntary appeal reviews are not available in the event of a lawsuit, or if you are enrolled in the following:

Health Maintenance Organization (HMO) Option; or

Exclusive Provider Organization (EPO) Option; or

Dental Maintenance Organization (DMO) Option; or

Dental Health Maintenance Organization (DHMO) Option; or

The Vision Plan.