Page 89 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Pre-Service Request for Benefits*

Type of Request for Benefits or Appeal Timing

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

You must then provide completed request for 45 days
Benefits information to the Claims Administrator
within:
The Claims Administrator must notify you of the benefit determination:

• if the initial request for Benefits is complete, 15 days
within:

• after receiving the completed request for 15 days
Benefits (if the initial request for Benefits is
incomplete), within:
You must appeal an adverse benefit 180 days after receiving the adverse benefit
determination no later than: determination
The Claims Administrator must notify you of the 15 days after receiving the first level appeal
first level appeal decision within:
You must appeal the first level appeal (file a 60 days after receiving the first level appeal
second level appeal) within: decision

The Plan Sponsor must notify you of the second 15 days after receiving the second level appeal
level appeal decision within:

*The Claims Administrator may require a one-time extension for the initial claim determination, of no more
than 15 days, only if more time is needed due to circumstances beyond control of the Plan.

Post-Service Claims

Type of Claim or Appeal Timing

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

You must then provide completed claim 45 days
information to the Claims 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 30 days
initial claim is incomplete), within:

You must appeal an adverse benefit 180 days after receiving the adverse benefit
determination no later than: determination

86 Section 6: Questions, Complaints and Appeals