Page 65 - 2023 Hickory Crawdads - Benefits Guide_Neat

general, claims must be filed in writing with Highmark Blue Cross Blue Shield. 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 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 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 below) 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 section below.

The ACA requires the 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 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 Highmark Blue Cross Blue Shield
or the Plan Administrator for more information on how to request an external review.

Statute of Limitations. A claim or action (i) to recover benefits allegedly due under the Plan
or by reason of any law, (ii) to enforce rights under the Plan, (iii) to clarify rights to future
benefits under the Plan, or (iv) that relates to the Plan and seeks a remedy, ruling or judgment
of any kind against the Plan or a Plan fiduciary or party in interest (collectively, a "Judicial
Claim"), may not be commenced in any court or forum until after the claimant has exhausted
the Plan's claims and appeals procedures (an "Administrative Claim"). A claimant must raise
every argument and/or produce all evidence the claimant believes supports the claim or
action in the Administrative Claim and shall be deemed to have waived any argument and/or
the right to produce any evidence not submitted to the Administrator or its delegate as part of
the Administrative Claim. Any Judicial Claim must be commenced in the appropriate court
or forum no later than 24 months from the earliest of (A) the date the first benefits were paid
or allegedly due; (B) the date the Plan Administrator or its delegate first denied the claimant's
request; or (C) the first date the claimant knew or should have known the principal facts on

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