Your appeal
The claims administrator
Pearl Insurance Group Llc
Send it to the appeal address on your denial letter or the back of your card. The filing names who processes claims for this plan.
Health plan & appeal guide
National Education Association of the United States
Self-funded · federal rules
Nea Members Insurance Plan · 2,528,845 people
Your employer pays the claims from its own money, so federal law (ERISA) applies — not your state’s insurance rules.
How we know · high confidence
- The filing says benefits are paid from a trust the plan controls.
- No medical insurance contract is on file (Schedule A).
- We ignored a small insurance contract with United American covering about 6,713 people; it is too small to be the main plan.
- Pearl Insurance Group Llc is paid to process this plan's claims (Schedule C), the usual setup when an employer pays claims itself.
Double-check in 30 seconds: “Self-funded”, “administered by” or “ASO” on your card or plan summary means self-funded. “Insured by” or “underwritten by” means insured.
Send your appeal here
Plan documents, and a copy of your appeal
The plan administrator
NATIONAL EDUCATION ASSOCIATION OF THE UNITED STATES
ATTN: PLAN ADMINISTRATOR
1201 16TH ST NW STE 813
WASHINGTON, DC 20036-3201The plan administrator is legally responsible for the plan. Ask in writing for the Summary Plan Description and the plan document. The plan administrator must send them within 30 days, or a court can add a penalty of up to $110 a day.
Know your deadlines
- Internal appeal to the plan180 days from the denial
- Independent external review4 months from the final denial
Dates you enter stay on this device.
What happens next
File in writing within 180 days of the denial notice. Ask for your complete claim file and the criteria they used. They must give it to you free. They decide within 30 days for care you haven't had yet, 60 days for care you already received.
If they say no again, request external review within 4 months of that final denial. The plan must send it to an independent review organization it contracts with. Some states let self-funded plans use the state's program instead. Your denial letter has to tell you where to send it. A reviewer outside the plan decides, usually within 45 days, and the plan must follow the decision.
If waiting could seriously harm your health, say so in writing. The plan must decide within 72 hours, and you can ask for expedited external review at the same time.
Call the Department of Labor's benefits advisors. They enforce these rules for employer plans and can contact the plan for you, free. After the appeals are finished, a lawyer can sue under ERISA if the denial was wrong.
Get free help
External review covers denials based on medical judgment ("not medically necessary", "experimental"), cancelled coverage, and surprise-billing disputes. A flat plan exclusion usually isn't eligible, but you can still file the internal appeal.
If your plan documents say the plan is "grandfathered" (unchanged since March 2010), the external-review rules may not apply.
Insured · state rules
Nea Long Term Care Insurance Program · 14,475 people
An insurance company pays the claims, so your state’s insurance rules apply and your state can help overrule a wrong denial.
How we know · high confidence
- Medical insurance bought from Transamerica Life, John Hancock Life, Mutual Of Omaha, The Prudential Insurance Company Of America is on file, covering about 14,454 people.
- The filing says all benefits are paid through insurance contracts.
- We ignored 1 low-cost supplemental policy(ies) such as accident or hospital cover; they don't decide how your medical claims are handled.
Double-check in 30 seconds: “Self-funded”, “administered by” or “ASO” on your card or plan summary means self-funded. “Insured by” or “underwritten by” means insured.
Send your appeal here
Your appeal
The insurance company on your card
Transamerica LifeJohn Hancock LifeMutual Of OmahaThe Prudential Insurance Company Of America
Send it to the appeal address printed on your denial letter (or the back of your card). Appeals go to the insurer, not your employer.
Plan documents
The plan administrator
NATIONAL EDUCATION ASSOCIATION OF THE UNITED STATES
ATTN: PLAN ADMINISTRATOR
1201 16TH ST NW STE 813
WASHINGTON, DC 20036-3201Ask in writing for the Summary Plan Description and the insurance certificate. Employer plans must send them within 30 days.
Know your deadlines
- Internal appeal to the insurance company180 days from the denial
- Independent external review4 months from the final denial
Dates you enter stay on this device.
What happens next
File in writing within 180 days of the denial notice. Ask for your complete claim file and the criteria they used. They must give it to you free. They decide within 30 days for care you haven't had yet, 60 days for care you already received.
If they say no again, request external review within 4 months of that final denial. It is run by the state where the policy was issued, usually your employer's home state (DC). The review is usually free. A reviewer outside the plan decides, usually within 45 days, and the plan must follow the decision.
If waiting could seriously harm your health, say so in writing. The plan must decide within 72 hours, and you can ask for expedited external review at the same time.
Get free help
External review covers denials based on medical judgment ("not medically necessary", "experimental"), cancelled coverage, and surprise-billing disputes. A flat plan exclusion usually isn't eligible, but you can still file the internal appeal.
If your plan documents say the plan is "grandfathered" (unchanged since March 2010), the external-review rules may not apply.
Not clear yet
Nea Hospital Income Insurance Program · 1,887 people
The filing doesn’t settle it. One question about your insurance card will.
How we know · low confidence
- No medical insurance contract is on file (Schedule A).
- The filing says all benefits are paid through insurance contracts.
- We ignored 1 low-cost supplemental policy(ies) such as accident or hospital cover; they don't decide how your medical claims are handled.
Double-check in 30 seconds: “Self-funded”, “administered by” or “ASO” on your card or plan summary means self-funded. “Insured by” or “underwritten by” means insured.
Is your plan insured or self-funded?
Look at your card or plan summary, or ask HR: “Is our medical plan fully insured or self-funded?”
Send your appeal here
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Know your deadlines
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What happens next
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Get free help
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Both kinds
The National Education Association and Affiliate Retiree Health Plan · 701 people
This employer has both kinds of coverage. The company on your insurance card decides which rules apply to you.
How we know · medium confidence
- The filing lists stop-loss insurance (Symetra Life). Employers buy stop-loss only when they pay claims out of their own money.
- The filing says benefits are paid from a trust the plan controls.
- Medical insurance bought from Kaiser Permanente is on file, covering about 48 people.
- We ignored a small insurance contract with Cigna covering about 3 people; it is too small to be the main plan.
- Medical insurance is on file, but the plan also pays benefits from the employer's own money, so some options are likely self-funded.
- The insured options cover only about 7% of the 701 participants, so most people in this plan are in the self-funded part.
- The self-funded part's claims are processed by UnitedHealthcare (Schedule C).
Double-check in 30 seconds: “Self-funded”, “administered by” or “ASO” on your card or plan summary means self-funded. “Insured by” or “underwritten by” means insured.
Which company is on your insurance card?
It’s printed on the front of the card. The filing shows which companies sell insured options here and which ones run the self-funded plan.
Send your appeal here
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Know your deadlines
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What happens next
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Get free help
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Both kinds
The National Education Association Welfare Benefit Plan · 644 people
This employer has both kinds of coverage. The company on your insurance card decides which rules apply to you.
How we know · medium confidence
- The filing says benefits are paid from the employer's general assets.
- Medical insurance bought from Kaiser Permanente is on file, covering about 14 people.
- Medical insurance is on file, but the plan also pays benefits from the employer's own money, so some options are likely self-funded.
- The insured options cover only about 2% of the 644 participants, so most people in this plan are in the self-funded part.
Double-check in 30 seconds: “Self-funded”, “administered by” or “ASO” on your card or plan summary means self-funded. “Insured by” or “underwritten by” means insured.
Which company is on your insurance card?
It’s printed on the front of the card. The filing shows which companies sell insured options here and which ones run the self-funded plan.
Send your appeal here
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Know your deadlines
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What happens next
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Get free help
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Both kinds
The National Education Association Welfare Benefit Plan II · 172 people
This employer has both kinds of coverage. The company on your insurance card decides which rules apply to you.
How we know · medium confidence
- The filing says benefits are paid from the employer's general assets.
- Medical insurance bought from Kaiser Permanente is on file, covering about 13 people.
- Medical insurance is on file, but the plan also pays benefits from the employer's own money, so some options are likely self-funded.
- The insured options cover only about 8% of the 172 participants, so most people in this plan are in the self-funded part.
Double-check in 30 seconds: “Self-funded”, “administered by” or “ASO” on your card or plan summary means self-funded. “Insured by” or “underwritten by” means insured.
Which company is on your insurance card?
It’s printed on the front of the card. The filing shows which companies sell insured options here and which ones run the self-funded plan.
Send your appeal here
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Know your deadlines
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What happens next
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Get free help
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Not clear yet
Nea Excess Major Medical Plan · 26 people
The filing doesn’t settle it. One question about your insurance card will.
How we know · low confidence
- No medical insurance contract is on file (Schedule A).
- The filing says all benefits are paid through insurance contracts.
- We ignored 1 low-cost supplemental policy(ies) such as accident or hospital cover; they don't decide how your medical claims are handled.
Double-check in 30 seconds: “Self-funded”, “administered by” or “ASO” on your card or plan summary means self-funded. “Insured by” or “underwritten by” means insured.
Is your plan insured or self-funded?
Look at your card or plan summary, or ask HR: “Is our medical plan fully insured or self-funded?”
Send your appeal here
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Know your deadlines
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What happens next
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Get free help
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Coming next
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