Page 142 - 2021 Medical Plan SPD

Claims and Appeal Notice

This Notice is provided to you in order to describe our responsibilities under Federal law for making
benefit determinations and your right to appeal adverse benefit determinations.

Benefit Determinations
Post-service Claims

Post-service claims are those claims that are filed for payment of Benefits after medical care has been
received. If your post-service claim is denied, you will receive a written notice from the Claims
Administrator within 30 days of receipt of the claim, as long as all needed information was provided with
the claim. The Claims Administrator will notify you within this 30 day period if additional information is
needed to process the claim, and may request a one time extension not longer than 15 days and pend
your claim until all information is received.
Once notified of the extension, you then have 45 days to provide this information. If all of the needed
information is received within the 45-day time frame, and the claim is denied, the Claims Administrator will
notify you of the denial within 15 days after the information is received. If you don't provide the needed
information within the 45-day period, your claim will be denied.
A denial notice will explain the reason for denial, refer to the part of the plan on which the denial is based,
and provide the claim appeal procedures.
If you have prescription drug Benefits and are asked to pay the full cost of a prescription when you fill it at
a retail or mail-order pharmacy, and if you believe that it should have been paid under the Plan, you may
submit a claim for reimbursement in accordance with the applicable claim filing procedures. If you pay a
Copayment and believe that the amount of the Copayment was incorrect, you also may submit a claim for
reimbursement in accordance with the applicable claim filing procedures. When you have filed a claim,
your claim will be treated under the same procedures for post-service group health plan claims as
described in this section.
Post-Service Claims

Type of Claim or Appeal Timing

If your claim is incomplete, the Claims Administrator must notify 30 days
you within:

You must then provide completed claim information to the Claims 45 days
Administrator within:

The 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:

You must appeal an adverse benefit determination no later than: 180 days after receiving
the adverse benefit
determination
The Claims Administrator must notify you of the first level appeal 30 days after receiving
decision within: the first level appeal

8 Federal Notice