Page 35 - 2022 MLB Umpire Benefit Guide Flipbook 1

MLB League-Wide Insurance Program
Plan and Summary Plan Description

Employer are not in any way responsiblefor the outcome of any dental treatment or care (or lack
of such treatment or care).

You should refer to the benefit booklets distributed to you to answer specificcoverage questions
and to help you decide which options (if more than one option is available to you) are right for
you and your family. Copies of these benefit booklets are also available from your Employer.

CLAIMS PROCEDURE
Please refer to the booklets and other descriptive materials you have received from the Board,
your Employer 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 theseseparate claims
and appeals procedureswill 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 writingwith Highmark Blue Cross Blue Shield. Amy 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 below. 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 benefitsor the circumstancesunder 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 tofile a claim. If a claim is received, but there is not enough information to allow
the Claims Administrator (identified in the ADDITIONALINFORMATIONsection below) toprocess
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 section below.

The ACA requires this Plan 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

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