Page 109 - 2022 Washington Nationals Flipbook

MLB LWIP & Nationals Welfare
Plans and Summary Plan Description

CLAIMS PROCEDURE

Please refer to the booklets and other descriptive materials you have received from the Plan
Administrator, the National, and insurance companies for the Plan’s claims procedures.
These booklets and other materials that describe a particular benefit under the Plan will
contain a specific set of claims and appeals procedures that you must follow to make a claim
to receive that particular benefit and/or to appeal a denied claim for that particular benefit.
Although these separate claims and appeals procedures will be very similar in most respects,
there may be important differences. Accordingly, you should follow the specific claims and
appeals procedures for a particular benefit very carefully. These documents are furnished
automatically, without charge, and as a separate document.

A request for benefits is a "claim" subject to these procedures only if it is filed by you or
your authorized representative in accordance with the Plan's claim filing guidelines. In
general, claims must be filed in writing with the appropriate insurer. Any claim that does not
relate to a specific benefit under the Plan (for example, a general eligibility claim or a dispute
involving a mid-year election change) must be filed with the Plan Administrator at the
address set forth in the ADDITIONAL INFORMATION section of each Appendix. A request for
prior approval of a benefit or service where prior approval is not required under the Plan is
not a “claim” under these rules. Similarly, a casual inquiry about benefits or the
circumstances under which benefits might be paid under the Plan is not a “claim” under these
rules, unless it is determined that your inquiry is an attempt to file a claim. If a claim is
received, but there is not enough information to allow the Claims Administrator (identified in
the ADDITIONAL INFORMATION section of the Appendices) to process the claim, you will be
given an opportunity to provide the missing information.

If you want to bring a claim for benefits under the Plan, you may designate an authorized
representative to act on your behalf so long as you provide written notice of such designation
to the Claims Administrator identifying such authorized representative. In the case of a
claim for medical benefits involving urgent care, a health care professional who has
knowledge of your medical condition may act as your authorized representative with or
without prior notice.

You must make initial claims for benefits under the Plan in writing to the Claims
Administrator at the address identified in the ADDITIONAL INFORMATION in the Appendices.

The ACA requires the LWIP and other group medical plans to comply with additional
internal claim and appeal procedure standards and offer claimants a new external review
option. The new external appeal option is available for certain final adverse benefit
determinations that do not relate to failure to meet the eligibility requirements under the Plan.
Specifically, an external review is available if the final adverse benefit determination relates
to a (a) medical judgment as determined by the external reviewer, or (b) rescission of
coverage. If your claim for benefits has been denied and you received a final adverse benefit
determination in response to your subsequent appeal, the notification of final adverse benefit
determination will provide instructions on how to request an external review. You may also
contact the Plan Administrator for more information on how to request an external review.

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