Page 57 - QCS.19 SPD - HSA
P. 57

Post-Service Claims
                                Type of Claim or Appeal                                  Timing
              If your claim is incomplete, Claims Administrator must notify you
                                                                                         30 days
              within:
              You must then provide completed claim information to Claims
                                                                                         45 days
              Administrator within:
              Claims Administrator must notify you of the benefit determination:
              if the initial claim is complete, within:                                  30 days
              after receiving the completed claim (if the initial claim is
                                                                                         30 days
              incomplete), within:
                                                                            180 days after receiving the adverse
              You must appeal an adverse benefit determination no later than:
                                                                                   benefit determination
              The Claims Administrator must notify you of the first level appeal  30 days after receiving the first level
              decision within:                                                           appeal
              You must appeal the first level appeal (file a second level appeal)  60 days after receiving the first level
              within:                                                                 appeal decision
              Claims Administrator must notify you of the second level appeal  30 days after receiving the second level
              decision within:                                                           appeal*

            *Claims Administrator may be entitled to a one-time extension of no more than 15 days only if more time is
            needed due to circumstances beyond their control.

            Appeals of Other Than Adverse Benefit Determinations
            If you or your authorized representative disagree with a determination other than those described under the
            procedures above, you or your authorized representative may ask to have it reviewed.
            A written request should be sent to the Claims Administrator within 180 calendar days of the date you or your
            authorized representative receive the adverse determination. The appeal may include:
               ·   written comments, documents, records, and other information relating to the determination; and

               ·   the ID numbers on your insured ID card.
            Please state the reason(s) you or your authorized representative disagree with the determination and include all
            information that may support the appeal.

            We will notify you or your authorized representative of the decision within 30 days of our receipt of the appeal
            request. If we deny your first appeal, a second appeal may be requested using the same procedures as required
            for the first. We will respond to the second appeal within 30 days of our receipt of the second appeal request; this
            completion of the second appeal will exhaust the appeal process.



























            Page 52                                                          Section 8- Questions, Complaints and Appeals
                                                                                                     HSA - 2017
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