Page 88 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

required, with: (i) any new or additional evidence considered, relied upon or generated by the Plan in
connection with the claim; and, (ii) a reasonable opportunity for any Covered Person to respond to such
new evidence or rationale.

Urgent Appeals that Require Immediate Action

Your appeal may require urgent action if a delay in treatment could increase the risk to your health, or the
ability to regain maximum function, or cause severe pain. In these urgent situations:
• The appeal does not need to be submitted in writing. You or your Physician should call the Claims
Administrator as soon as possible.
• The Claims Administrator will provide you with a written or electronic determination within 72 hours
following receipt of your request for review of the determination, taking into account the
seriousness of your condition.
• If the Claims Administrator needs more information from your Physician to make a decision, the
Claims Administrator will notify you of the decision by the end of the next business day following
receipt of the required information.

The appeal process for urgent situations does not apply to prescheduled treatments, therapies or
surgeries.

Urgent Care Request for Benefits*

Type of Request for Benefits or Appeal Timing
If your request for Benefits is incomplete, the 24 hours
Claims Administrator must notify you within:
You must then provide completed request for 48 hours after receiving notice of additional
Benefits to the Claims Administrator within: information required
The Claims Administrator must notify you of the 72 hours
benefit determination within:
If the Claims Administrator denies your request for 180 days after receiving the adverse benefit
Benefits, you must appeal an adverse benefit determination
determination no later than:
The Claims Administrator must notify you of the 72 hours after receiving the appeal
appeal decision within:
*You do not need to submit urgent care appeals in writing. You should call the Claims Administrator as
soon as possible to appeal an urgent care request for Benefits.

Pre-Service Request for Benefits*

Type of Request for Benefits or Appeal Timing
If your request for Benefits is filed improperly, the 5 days
Claims Administrator must notify you within:

85 Section 6: Questions, Complaints and Appeals