Page 143 - 2021 Medical Plan SPD

Post-Service Claims

Type of Claim or Appeal Timing
You must appeal the first level appeal (file a second level appeal) 60 days after receiving
within: the first level appeal
decision

The Claims Fiduciary must notify you of the second level appeal 30 days after receiving
decision within: the second level appeal

Pre-service Requests for Benefits
Pre-service requests for Benefits are those requests that require notification or approval prior to receiving
medical care. If you have a pre-service request for Benefits, and it was submitted properly with all needed
information, the Claims Administrator will send you written notice of the decision from the Claims
Administrator within 15 days of receipt of the request. If you filed a pre-service request for Benefits
improperly, the Claims Administrator will notify you of the improper filing and how to correct it within five
days after the pre-service request for Benefits was received. If additional information is needed to process
the pre-service request, the Claims Administrator will notify you of the information needed within 15 days
after it was received and may request a one time extension not longer than 15 days and pend your
request 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, the Claims
Administrator will notify you of the determination within 15 days after the information is received. If you
don't provide the needed information within the 45-day period, your request for Benefits 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 appeal procedures.
If you have prescription drug Benefits and a retail or mail order pharmacy fails to fill a prescription that
you have presented, you may file a pre-service health request for Benefits in accordance with the
applicable claim filing procedure. When you have filed a request for Benefits, your request will be treated
under the same procedures for pre-service group health plan requests for Benefits as described in this
section.

Pre-Service Request for Benefits*
Type of Request for Benefits or Appeal Timing

If your request for Benefits is filed improperly, the Claims 5 days
Administrator must notify you within:

If your request for Benefits is incomplete, the Claims 15 days
Administrator must notify you within:

You must then provide completed request for Benefits information 45 days
to the Claims Administrator within:

The Claims Administrator must notify you of the benefit determination:

• if the initial request for Benefits is complete, within: 15 days
• after receiving the completed request for Benefits (if the 15 days
initial request for Benefits is incomplete), within:
You must appeal an adverse benefit determination no later than: 180 days after receiving
the adverse benefit
determination

9 Federal Notice