CLAIMS DENIALS

If your claim for benefits is wholly or partially denied, you will receive a written notice of denial that will contain the following information:

1. The specific reason for the denial with specific reference to pertinent Plan provisions on which the denial is based;
2. A description of any additional material or information necessary for you to perfect the claim and an explanation of why such material is necessary; and
3. Appropriate information as to the steps to be taken if you wish to submit the claim for review.
4. The specific rule, guideline, protocol, or other similar criterion, if any, relied upon in making the determination; and
5. An explanation of the scientific or clinical judgment for the determination if the adverse benefit determination was based on medical necessity or other similar exclusion or limitation.

Emergency Care Claims

In the case of an Emergency Care claim, the Administrative Office shall notify you of the Plan’s benefit determination (whether adverse or not) as soon as possible, taking into account the seriousness of your medical condition, but not later than 72 hours after receipt of the claim by the Plan, unless you fail to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan. In the case of such a failure, the Administrative Office shall notify you within 24 hours after receipt of the claim by the Plan, of the specific information necessary to complete the claim. You shall be given a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. The Administrative Office shall notify you of the Plan’s benefit determination as soon as possible, but in no case later than 48 hours after the earlier of: (1) the Plan’s receipt of the specified information; or (2) the end of the period given to you to provide the specified additional information.

Pre-Service Claims

The benefit determination, whether adverse or not, shall be given within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after the claim is filed, and unless special circumstances beyond the control of the Plan require an extension of time for processing the claim. If such extension is required, you will be sent written notice before the expiration of the initial 15 day period, stating the special circumstances requiring the extension and the date by which a decision on the claim can be expected. If such extension is necessary due to a failure by you to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and you shall be given at least 45 days from the receipt of the notice within which to provide the specified information.

Post-Service Claims

The notice of denial shall be given within 30 days after the claim is filed, and unless special circumstances beyond the control of the Plan require an extension of time for processing the claim. If such extension is required, you will be sent written notice before the expiration of the initial 30 day period, stating the special circumstances requiring the extension and the date by which a decision on the claim can be expected. If such extension is necessary due to a failure by you to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and you shall be given at least 45 days from the receipt of the notice within which to provide the specified information.

Concurrent Care Decision

If you are receiving an ongoing course of treatment to be provided over a period of time or number of treatments, any reduction or termination by the Plan of such treatment shall be deemed an adverse benefit determination. Notice of such determination shall be sent at a time sufficiently in advance of the reduction or termination to allow you to appeal and obtain a determination on review of that adverse benefit determination before the benefit is reduced or terminated.

Any request by you to extend the course of treatment beyond the period of time or number of treatments involving an Emergency Care claim shall be decided as soon as possible, taking into account the seriousness of your medical condition, and the Administrative Office shall notify you of the benefit determination, whether adverse or not, within 24 hours prior to the expiration of the prescribed period of time or number of treatments. The appeal procedure is stated below.