Page 141 - Washington Nationals 2023 Benefits Guide -10.26.22_Neat

MLB League-Wide Insurance Program
Plan and Summary Plan Description

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 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.

External Review. The ACA requires the non-grandfathered medical benefit option(s) provided
under the Plan to comply with additional internal claim and appeal procedure standards and
offer claimants a new external review option. The 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.

COVID-19 Extensions. Due to the COVID-19 pandemic, the timelines for appealing an
adverse benefit determination (and any appropriate extension) and requesting external review
(if applicable) will be disregarded effective March 1, 2020. This special rule will remain in
effect until the date that is 60 days following the end of the COVID-19 emergency (or such
other date announced by the U.S. Department of Labor and the Internal Revenue Service).
Contact the Claims Administrator if you have any questions.

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