Health plan & appeal guide

PMC, LLC

Miami, FL · Form 5500 filing, plan year 2024

Insured · state rules PMC, LLC - Cafeteria & Erisa Wrap Plan · 513 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 Blue Cross Blue Shield, Kaiser Permanente, Sutter Health Plus, UnitedHealthcare, Western Health Advantage, Humana, Compbenefits is on file, covering about 603 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.

  1. Send your appeal here

    State-regulated plan (fully insured)

    Your employer buys this coverage from an insurance company. The insurer decides claims, and your state's insurance regulator oversees it.

    Your appeal

    The insurance company on your card

    Blue Cross Blue ShieldKaiser PermanenteSutter Health PlusUnitedHealthcareWestern Health AdvantageHumanaCompbenefits

    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

    PMC, LLC
    ATTN: PLAN ADMINISTRATOR
    5800 NW 171ST STREET
    MIAMI, FL 33015
    (305) 779-4079

    Ask in writing for the Summary Plan Description and the insurance certificate. Employer plans must send them within 30 days.

  2. 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.

  3. What happens next

    1. Internal appeal to the insurance company

      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.

    2. Independent external review

      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 (FL). The review is usually free. A reviewer outside the plan decides, usually within 45 days, and the plan must follow the decision.

    3. Urgent? Ask for an expedited review

      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.

  4. 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.

Coming next

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