Disability Service Claim Status

Question 1

May be due to:

• Claim newly filed with current/past DLW, not yet in process.
• Early claim submission with future DLW.

Review History to Determine Status

- Confirm if DLW, Date of Disability (FDA) on file are still correct.
- Check Scheduled Tasks/Claim History to:
- Confirm if Medical Authorization has been received.
- Locate any indication of information needed per CS to process the claim.

Answer 1

No Status

Reference Knowledge Article: “No Status Claim Status” for additional details.

Question 2

IVR indicates “We are currently reviewing…”

May be due to-

• New claim not yet in research due to missing required fields.
• New claim in Research, not yet worked by Claim Specialist (CS)
• Incomplete due to overpayment reasons in a prior claim for EE.

Answer 2

Incomplete

Reference Knowledge Article: “Incomplete Claim Status” for additional details.

Question 3

IVR indicates “We are currently reviewing…”
-Additional info is required to make initial decision.

Important:

• Do not provide reference to approval dates from decision screen
• Follow special handling for LTD or SHU LTD claim if applicable; otherwise see below.

If Information received, but still pending review:
-Advise: Next steps - claim in review

If Information is not received:
-Research: Check Scheduled Tasks and Claim History to find out what information is needed (e.g., research needs) to
process the claim.
-Follow instructions and advise per guidelines in the appropriate article below :
-Claim Status: Info Not Received from ER
-Claim Status: Info Not Yet Received / Next Steps

Answer 3

Pending

Reference Knowledge Article: “Pending Claim Status” for additional details.

Question 4

IVR indicates “I need to transfer you…”

• Claim decision requires 2nd level of review/release by Claims Office.
• Payment may exceed Claim Specialist (CS) approval threshold.

NOTE: Do not provide approval dates, check/payment information, etc..

If longer than 2 business days and CS has not contacted EE:
-Send escalation email.

Answer 4

Exceeds Authority

Reference Knowledge Article: “Exceeds Authority Claim Status” for additional details.

Question 5

Certified (FMLA) does not equal approved.

FMLA Explanation of Frequency and Duration

• Episode Frequency:
  
  • Number of times per week/month/year EE is to be out of work.

Episode Duration:
-Length of time the EE is certified to take FML for the specific leave event.

IVR states:

• (STD): “Approved”
• (FMLA): “I will transfer…”

IVR will also state approved through date, payment amount, method, last payment date (if MetLife issues payments)

Answer 5

Active/Approved/Certified

Reference Knowledge Article: “Active/Approved/Certified Claim Status” for additional details.

Question 6

Claim has been denied for particular reason and claimant will NOT be paid any benefits.
IVR indicates “I will need to transfer you…”
-Research
-Determine if caller can be advised of Status:
-Denial Letters: Can a Denial Be Relayed to Callers?

Possible Reasons for Denied Status:
Medical Not Received | Medical Does Not Support | Plan Provisions Not Met | No Response From ER.

Answer 6

Declined or Denied STD/LTD Claims

Reference Knowledge Article: “Decline or Denied STD/LTD Claim Status” for additional details.

Question 7

There is no appeal process.

Possible Reasons for Status:

Eligibility

- Federal Requirements: EE must be employed for 12 months and have worked 1250 hours in the past 12 months.
- State Requirements: varies by state. See State Leave Law requirements.
- Company Policy: See Employer Company Policy in group specifics.

• HCPC not received or received incomplete.
  
  • HCPC must be received within 15 days of filing the claim under Federal Law.
  • HCPC was missing information or was not provided.
• Health condition not considered Serious Health Condition.
• Family member not a Qualified Family Member.
• Leave type is not a Qualifying Leave Type.
• HCPC was missing information or was not provided.

Answer 7

Decline or Denied FMLA Claim Status

Reference Knowledge Article: “Decline or Denied FMLA Claim Status” for additional details.

Question 8

IVR indicates “I need to transfer you…”

• Additional info is required to make claim extension decision
• Special handling required for LTD or SHU LTD Claims

NOTE:
-New Claim No Decision Made: Do not provide reference to approval dates from decision screen when the claim is in
waiting status.
-Claim Decision Made: If claim was previously approved then is moved to waiting status: advise caller of previous approval
dates.

Answer 8

Suspended or Waiting Claim Status

Reference Knowledge Article: “Suspended or Waiting Claim Status” for additional details.

Question 9

IVR indicates “Closed as of [–/–/–]”

• Medical information to support the claim beyond [claim end date] may not have been received.
• Claim benefits may have reached maximum duration.
• Employee (EE) may have returned to work.

Answer 9

Closed, Ended, Abandoned Claim Status

Reference Knowledge Article: “Closed, Ended, Abandoned Claim Status” for additional details.

Question 10

Claim previous denied and claimant does not agree with decision made on claim.

Answer 10

Appeal Claim Status

Reference Knowledge Article: “Appeal Claim Status” for additional details.