Health Account Claims and Appeals
Claims
If a Health Account claim you submit is denied in part or whole, YSA or KPIC, as the third-party Claims Administrator, will provide you with written notice within 30 days of receiving your claim, with an explanation of why the claim was denied and any materials you can submit that would reverse the denial or perfect the claim. In certain cases an additional 15 days may be required by your Claims Administrator to respond to you. If an extension is required, you will be notified of this extension within the initial 30 days from the date of the Claims Administrators receipt of your claim.
Send your claims to:
If you are an Anthem member
If you are a KPIC member
Your Spending Account (YSA)
P.O. Box 785040
Orlando, FL 32878-5040
Kaiser Foundation Health Plan Inc. SF
C/O Health Payment Services
P.O. Box 1540
Fargo, ND 58107-1540
If YSA or KPIC needs additional information from you, you'll be given 45 days from the receipt of this notice to provide the additional information. In this case, the third-party Claims Administrator will respond in writing within 15 days after receiving your additional information.
Appeals
If you believe this initial determination results in the denial of a Health Account benefit to which you may be entitled, you may appeal to the Plan Administrator.
Send your first appeal to:
If you are an Anthem member
If you are a KPIC member
Your Spending Account (YSA)
P.O. Box 785040
Orlando, FL 32878-5040
Kaiser Health Payment Services
c/o HSA
P.O. Box 1540
Fargo, ND 58107-1540
This appeal must be made in writing within 180 days after receiving written notice of the denial from YSA if you are an Anthem member or from KPIC if you are a KPIC member and must contain the following information:
  • the reason(s) for making the appeal;
  • the facts supporting the appeal;
  • the amount claimed; and
  • the name and address of the person filing the appeal (claimant).
To expedite processing, you should also include a HIPAA AUTHORIZATION TO USE AND/OR DISCLOSE PERSONAL HEALTH INFORMATION form. You can access a copy online from the Human Resources Forms section of the PG&E@Work intranet site or by calling the PG&E Benefits Service Center at 866-271-8144 (open weekdays from 7:30 a.m. to 5 p.m. Pacific time).
YSA or Kaiser Health Payment Services will generally make a decision within 60 days after receiving the appeal and mail or email a copy of the decision to you promptly. The decision will either overrule or uphold the Plan Administrator's earlier determination, based on plan parameters and guidelines received from PG&E. The decision will give specific reasons and references to the Health Account Plan provisions which support YSA's or KPIC's decision.
Questions About Claims for Reimbursement
You should refer any questions about your claims for reimbursement to your Claims Administrator at the following address and phone numbers.
If you are covered by YSA:
Your Spending Account (YSA)
P.O. Box 785040
Orlando, FL 32878-5040
800-964-9902
If you are covered by KPIC:
Kaiser Foundation Health Plan Inc. SF
C/O Health Payment Services
P.O. Box 1540
Fargo, ND 58107-1540
877-750-3399
PG&E's Voluntary Claims and Appeals Review Process
If you are not satisfied with the claims and appeals review process completed with YSA or KPIC, as applicable, you may elect to use PG&E's Voluntary Claims and Appeal Review Process. You have 90 days from the date of receipt of the final decision from YSA or KPIC to elect this claims and appeals review process.
The first step of the Voluntary Claims and Appeals Review Process is to write to the Benefits Department, requesting a review of your appeal. Your appeal should include all pertinent documentation. To expedite processing, you should also include a HIPAA AUTHORIZATION TO USE AND/OR DISCLOSE PERSONAL HEALTH INFORMATION form. You can access a copy online from the Human Resources Forms section of the PG&E@Work intranet or by calling the PG&E Benefits Service Center at 866-271-8144 (open weekdays from 7:30 a.m. to 5 p.m. Pacific time).
Send your appeal to:
Pacific Gas and Electric Company
Benefits Department
Appeals
1850 Gateway Blvd., 7th Floor
Concord, CA 94520
The Benefits Department will review your appeal and make a decision within 60 days of the date on which the appeal is received (non-receipt of the HIPAA Authorization may delay your appeal). There may be special circumstances where an extension of up to an additional 90 days may be required. You will be notified if such an issue occurs. If the Benefits Department denies your claim, you will receive a written response that will include:
  • the reason(s) for the denial;
  • a reference to the Plan provision(s) which apply to the denial; and
  • an explanation of additional appeals procedures.
You may then have your appeal reviewed by the Employee Benefit Appeals Committee (EBAC). To do so, you must submit a new appeal in writing within 60 days of the date on which you received the Step One denial. Your appeal should state the reason(s) for your appeal and should include all relevant documentation and information supporting your appeal. Unless there are special circumstances where an extension of up to an additional 90 days may be required, you shall receive EBAC's decision within 90 days of EBAC's receipt of the appeal.
Send your appeal to:
Pacific Gas and Electric Company
Benefits Department
EBAC Appeals
1850 Gateway Blvd., 7th Floor
Concord, CA 94520
If EBAC denies your appeal, you will receive a written response which will include:
  • the specific reason(s) for the denial;
  • a reference to the specific Plan provision(s) on which the denial is based;
  • a statement that you are 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 for benefits; and
  • a statement of your right to bring a civil action under section 502(a) of ERISA.
Using this voluntary process does not restrict your ability to file suit.