Page 21 - Vision Benefits Plan Document

TEXAS MUTUAL INSURANCE COMPANY VISION PLAN

■ the patient's name and identification number;

■ the date(s) of service(s);
■ the provider's name;
■ the reason you believe the claim should be paid; and

■ any new information to support your request for claim payment.

UnitedHealthcare Vision will notify you of its decision regarding reconsideration of your
complaint within 60 days of receiving it. If you are not satisfied with the decision, you have
the right to take your complaint to the Office of the Commissioner of Insurance.

Appeals should be submitted to:

UnitedHealthcare Vision Claims Department
P.O. Box 30978
Salt Lake City, Utah 84130

Telephone inquiries concerning appeals should be made to: UnitedHealthcare Vision Claims,
Appeals Department, 1-800-638-3120.

Complaint Hearing
If you request a hearing, UnitedHealthcare Vision will appoint a committee to resolve or
recommend the resolution of your complaint. If your complaint is related to clinical matters,
UnitedHealthcare Vision may consult with, or seek the participation of, medical and/or
vision experts as part of the complaint resolution process.

The committee will advise you of the date and place of your complaint hearing. The hearing
will be held within 60 days following the receipt of your request by UnitedHealthcare Vision,
at which time the committee will review testimony, explanation or other information that it
decides is necessary for a fair review of the complaint.

UnitedHealthcare Vision will send you written notification of the committee's decision
within 30 days of the conclusion of the hearing.

17 SECTION 7 - CLAIMS PROCEDURES