Can Administrator Change Claim Amount?

[Guest JMD67]

If an adminitrator receives a claim form, filled out and signed by the participant for - let's say a medical reimbursement claim.

The receipt shows $235.00 paid for vision care and that is what is on the claim form as a single figure. However reading over the documentation, the administrator discovers that $35.00 of that claim is for a supplemental warranty/service agreement.

Is it ok for the administrator just enter in and pay the $200.00 and deny the $35.00 portion thus changing the original figure that the participant signed on... or should the administrator deny the claim entirely and ask the participant to resubmit the entire claim and fill out the claim form with the correct figure.

What about the opposite scenario... if the claim form is filled out for $47 but the documentation clearly shows it was $74... can the administrator just enter in the $74 ??

[Sandra Pearce]

I do not actually pay 125 spending account claims myself, but represent an employer/sponsor of a 125 plan. If I were paying the claims in the first example I would reimburse the allowable amount of $200 and deny the disallowed amount of $35. In the second example I would only pay the requested amount of $47 because it is possible that, instead of a transposition in the figures, the employee is expecting an additional reimbursement from another source.

[oriecat]

This is only my opinion -

Scenario 1 - Yes, I think paying the appropriate amount ($200) is fine. You're not changing the claim amount, you're just paying the amount that is approved and denying the part that isn't.

Scenario 2 - No, I think you should pay only what was submitted for, and then approved. Sometimes people might want to leave funds in for a while to save for another occasion. I wouldn't make assumptions about their intent.

[oriecat]

I got scooped!

[Lisa Hand]

Any change to the original claim should be clearly documented in writing as to why it was changed,

the regulation requiring the change and portion of plan document which requires it. Additionally, it must include an explaination of how to appeal the ruling, the timeframe in which to do so and the timeframe in which the response to the appeal will be forwarded.