Page 20 - Vision Benefits Plan Document

TEXAS MUTUAL INSURANCE COMPANY VISION PLAN

UnitedHealthcare Vision Claims Department
P.O. Box 30978
Salt Lake City, Utah 84130
FAX: (248) 733-6060

Please note: Receipts for services and materials purchased on different dates must be
submitted together at the same time to receive reimbursement.

Failure to provide all the information listed above may delay any reimbursement that may be
due you.

After UnitedHealthcare Vision has processed your claim, you will receive payment for
Benefits that the Plan allows. It is your responsibility to pay the non-Network provider the
charges you incurred, including any difference between what you were billed and what the
Plan paid.

Examination of Covered Persons
In the event of a question or dispute concerning coverage for vision Services,
UnitedHealthcare Vision may reasonably require that a Covered Person be examined at
UnitedHealthcare Vision's expense by a Network Provider acceptable to the Company.

Explanation of Benefits (EOB)

You may receive an Explanation of Benefits (EOB) after processing the claim. The EOB
will let you know if there is any portion of the claim you need to pay. If any claims are
denied in whole or in part, the EOB will include the reason for the denial or partial payment.
You can also view and print all of your EOBs online at www.myuhcvision.com. See
Section 10, Glossary for the definition of Explanation of Benefits.

Important
All claim forms must be submitted within 12 months after the date of service. Otherwise,
the Plan will not pay any Benefits for that Eligible Expense. This 12-month requirement
does not apply if you are legally incapacitated.

Claim Denials and Appeals

If Your Claim is Denied
If a claim for Benefits is denied in part or in whole, you may call UnitedHealthcare Vision
before requesting a formal appeal. If UnitedHealthcare Vision cannot resolve the issue to
your satisfaction over the phone, a representative can provide you with the appropriate
address to submit a written complaint. UnitedHealthcare Vision will notify you of its
decision regarding your complaint within 30 days of receiving it.

How to Appeal a Denied Claim
If you disagree with UnitedHealthcare Vision's decision after having submitted a written
complaint, you can ask UnitedHealthcare Vision in writing to formally reconsider your
complaint. If your complaint relates to a claim for payment, your request should include:

16 SECTION 7 - CLAIMS PROCEDURES