Claims and Appeals Review Procedures Under ERISA

When a participant (or the participant's beneficiary, where applicable) files a claim with the insurance carrier, the participant's claim will be promptly evaluated. Within 45 days after the participant's claim has been received, the participant will be provided with:

• A written decision on the participant's claim; or
• A notice that the period to decide the participant's claim is being extended for 30 days.

Before the end of this extension period, the participant will be sent:

• A written decision on the participant's claim; or
• A notice that the period to decide the participant's claim is being extended for an additional 30 days.

If an extension is due to the participant's failure to provide information necessary to decide the claim, the extended time period for deciding the participant's claim will not begin until the participant provides the necessary information.

If the period to decide the participant's claim is extended, the participant will be notified of the following:

• The reasons for the extension;
• When it is expected that the decision on the participant's claim will be made;
• An explanation of the standards on which entitlement to benefits is based;
• Any unresolved issues preventing a decision; and
• Any additional information needed to resolve those issues.

If additional information is requested, the participant will have 45 days to provide the information. If the participant does not provide the requested information within 45 days, the participant's claim may be decided based on the information that has been received.

If all or part of the participant's claim is denied, the participant will receive a written notice of denial containing:

• The specific reasons for the decision;
• Reference to the specific provisions of the plan documents on which the decision is based;
• A description of any additional information needed to support the participant's claim and an explanation of why it is needed;
• Information describing procedures and time limits to appeal the decision;
• Information concerning the participant's right to receive, free of charge upon request, copies of non-privileged documents and records relevant to the participant's claim;
• Any internal rule, guidelines, protocol or similar criterion relied on in making the decision; and
• A statement of the participant's right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination following an appeal.

The notice of determination may be provided in written or electronic form. Electronic notices will be provided in a form that complies with any applicable legal requirements.

If all or part of the participant's claim is denied, the participant may request an appeal. The participant must request a review of the denied claim in writing within 180 days after receiving notice of the denial. The participant's request should be sent to the address specified in the claims denial.

The participant may also send written comments or other items to support his or her claim. The participant may review and receive copies, free of charge, of any non-privileged information that is relevant to his or her request for an appeal. The participant may also request the names of medical or vocational experts who provided advice about his or her claim.

The person conducting the review will be someone other than the person who denied the claim and will not be subordinate to that person. The person conducting the review will not give deference to the initial denial decision. If the denial was based on a medical judgment, the person conducting the review will consult with a qualified health care professional. This health care professional will be someone other than the person who made the original medical judgment and will not be subordinate to that person.

The appeal will include any written comments or other items the participant submits to support his or her claim.

The participant's claim will be promptly reviewed following receipt of all necessary information. Within 45 days after receipt of the participant's request for an appeal, the participant will be sent:

• A written decision on the appeal; or
• A notice that the review period is being extended for 45 days.

If the extension is due to the participant's failure to provide information necessary to decide the appeal, the extended time period for review of the participant's claim will not begin until the participant provides the necessary information. If the participant does not provide the requested information within 45 days, a decision on the review of the participant's claim may be based on the information that has been received. 

If the review period is extended, the participant will be notified of the following:

• The reasons for the extension;
• When a decision on the participant's appeal is expected; and
• Any additional information needed to decide the participant's claim.

If additional information is requested, the participant will have 45 days to provide the information. If the participant does not provide the requested information within 45 days, a decision on the review of the participant's claim may be based on the information that has been received.

Following the re-review, if all or part of the participant's claim is denied, he or she will receive a written notice of denial containing:

• The specific reasons for the decision;
• Reference to the specific provisions of the plan documents on which the decision is based;
• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the decision;
• Information concerning the participant's right to receive, free of charge, copies of non-privileged documents and records relevant to the participant's claim upon request;
• A statement of the participant's right to bring a civil action under Section 502(a) of ERISA; and
• A statement that "The participant or the plan administrator may have other voluntary alternative dispute resolution options, such as mediation. One way for the participant to find out what may be available is to contact his or her local U.S. Department of Labor Office or state insurance regulatory agency."

The notice of determination may be provided in written or electronic form. Electronic notes will be provided in a form that complies with any applicable legal requirements.

• Claim: Any request for plan benefits made in accordance with the plan's claims filing procedures, including any request for a service that must be pre-approved.
• Urgent Care Claim: Any claim for medical care or treatment that has to be decided more quickly because the normal timeframes for decision-making could seriously jeopardize the participant's life or health or the participant's ability to regain maximum function, or in the opinion of a physician with knowledge of the participant's condition, could subject the participant to severe pain that cannot be adequately managed without the care or treatment addressed in the claim.
• Pre-service Claim: Any claim for a benefit — other than an urgent care claim — that must be approved in advance of receiving medical care (for example, requests to pre-certify a hospital stay or for pre-approval under a utilization review program).
• Post-service Claim: Any other type of claim.
• Concurrent Care Decision: Any decision in which the plan — after having previously approved an ongoing course of treatment provided over a period of time or a specific number of treatments — subsequently reduces or terminates coverage for the treatments (other than by plan amendment or termination).
• Adverse Decision or Adverse Decision on Appeal: A denial, reduction, or termination of, or a failure to provide or make, payment (in whole or in part) for a benefit. An adverse decision includes a decision to deny benefits based on:
  • An individual's being ineligible to participate in the plan;
  • Utilization review;
  • A service's being characterized as experimental or investigational or not medically necessary or appropriate; and
  • A concurrent care decision.
• Authorized Representative: An individual authorized to act on the participant's behalf in pursuing a claim or appeal in accordance with procedures established by the plan. For urgent care claims, a health care professional with knowledge of the participant's medical condition may act as an authorized representative. (A health care professional is a physician or other health care professional who is licensed, accredited, or certified to perform specified health services consistent with state law.) For information about appointing an authorized representative, contact Human Resources.

The participant must file a claim for benefits within the time specified by the benefit plan and in accordance with the plan's established claim procedures.

If a pre-service claim is incorrectly filed according to the plan's claim procedures, the participant will be notified as soon as possible, but no later than five days after the claim is received by the plan. If the incorrectly filed pre-service claim is an urgent care case, the participant will be notified within 24 hours. Notice of an improperly filed pre-service claim may be provided orally — or in writing, if the participant requests so. The notice will identify the proper procedures to be followed in filing the claim.

In order to receive notice of an improperly filed pre-service claim, the participant or an authorized representative must have provided a communication regarding the claim to the person or organizational unit that customarily handles benefit matters for the plan. The communication must include:

• The identity of the claimant;
• A specific medical condition or symptom; and
• A request for approval for a specific treatment, service or product.

If a properly filed urgent care claim is missing information needed for a coverage decision, the participant will be notified by the plan as soon as possible, but no later than 24 hours after the claim has been received by the plan. The participant will be notified of the specific information necessary to complete the claim. The participant will have a reasonable amount of time considering the circumstances (but not less than 48 hours) to provide the specific information. The plan will then provide notice of the claim decision as soon as possible, but no later than 48 hours after the earlier of the following:

• The date the plan receives the specified information; or
• The end of the additional time period given for providing the information.

After the participant's claim is reviewed by the plan, the participant will receive a notice of benefit determination within the timeframes specified below. For urgent care and pre-service claims, the participant will receive a notice of benefit determination whether or not the plan makes an adverse decision on the participant's claim. For post-service and concurrent care claims, the participant is entitled to receive a notice of benefit determination if the plan makes an adverse decision on, or denies, the participant's claim.

The timeframes for providing notice of a benefit determination generally start when a written claim for benefits is received by the plan. Notice of a benefit determination may be provided in writing by in-hand, mail, or electronic delivery. However, in some urgent cases, the participant may first be provided notice orally, which will be followed by written or electronic notice within three days. Note, "days" means calendar (not business) days. The timeframes for providing a notice of benefit determination are as follows:

• Urgent Care Claims: As soon as possible considering the medical urgency, but no later than 72 hours after the plan receives the participant's claim.
• Pre-service Claims: Within a reasonable period of time appropriate to the medical circumstances, but no later than 15 days after the plan receives the participant's claim. This timeframe may be extended for up to 15 days for matters beyond the plan's control.
• Post-service Claims: In the case of an adverse decision, within a reasonable period of time, but no later than 30 days after the plan receives participant's claim. This timeframe may be extended for up to 15 days for matters beyond the plan's control.
• Concurrent Care Decisions: If an ongoing course of treatment will be reduced or terminated, the participant will be notified sufficiently in advance to provide an opportunity to appeal and obtain a decision on appeal before a benefit is reduced or terminated.

If the participant requests an extension of ongoing treatment in an urgent circumstance, the participant will be notified as soon as possible given the medical urgency, but no later than 24 hours after the plan receives the claim — provided the claim is submitted to the plan at least 24 hours before the expiration of the prescribed time period or number of treatments.

If the participant requests an extension of ongoing treatment in a non-urgent circumstance, the request will be considered a new claim and decided according to post-service or pre-service timeframes, whichever applies.

For pre-service and post-service claims, the plan may extend the timeframe for making a decision on the participant's claim in certain cases. If an extension is necessary, the participant will be notified before the end of the initial timeframe (15 days for pre-service claims; 30 days for post-service claims) of the reasons for the delay and when the plan expects to make a decision. Further, if an extension is necessary because certain information was not submitted with the claim, the notice will describe the required information that is missing, and the participant will be given an additional period of at least 45 days after receiving the notice to furnish the information. The plan's extension period will begin when the participant responds to the request for additional information. The plan will then notify the participant of the benefit determination within 15 days after a response is received.

If the participant disagrees with the decision on a claim, the participant (or an authorized representative) may file a written appeal with the plan within 180 days after receipt of the notice of adverse decision. If the participant does not appeal on time, the participant may lose the right to file suit in a state or federal court, as the participant will not have exhausted internal administrative appeal rights (which is generally a requirement before suing in state or federal court).

The participant should include the reasons he or she believes the claim was improperly denied, and all additional facts and documents the participant considers relevant in support of the appeal. The decision on the participant's appeal will consider all comments, documents, records, and other information submitted, even if they were not submitted or considered during the initial claim decision.

A new decision-maker will review the denied claim — the appeal will not be conducted by the individual who denied the initial claim or by that person's subordinate. The new decision-maker will not give deference to the original decision on the participant's claim. That is, the reviewer will give the claim a "fresh look" and make an independent decision about the claim.

If the participant's claim was denied based on medical judgment, the reviewer will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the claim. The health care professional will not be the same person (and will not be a subordinate of the person) who was consulted on the initial decision. (A medical judgment includes whether a treatment, drug or other item is experimental, investigational or not medically necessary or appropriate.) The plan will also identify any medical or other experts whose advice was obtained in considering the original decision on the claim, whether or not the plan relied on their advice.

For appeals of adverse benefit decisions involving urgent care claims, the plan will accept either oral or written requests for appeals for an expedited review. All necessary information may be transmitted between the plan and the participant or health plan providers by telephone, fax or other available expeditious methods.

Second Level of Appeal
If a participant is dissatisfied with an appeal decision on a claim, he or she may:

• For urgent care claims, file a second level of appeal, and receive notification of a decision not later than 36 hours after the appeal is received.
• For pre-service or post-service claims, file a second level of appeal within 60 days of receipt of the level one appeal decision, and receive notification of a decision not later than 15 days (for pre-service claims) or 30 days (for post-service claims) after the appeal is received.

If a participant does not agree with the final determination on review, he or she has the right to bring a civil action under Section 501(a) of ERISA, if applicable.

After the participant's appeal is reviewed by the plan, the participant will receive a notice of decision on appeal within the timeframes specified below. The participant will receive a notice of decision on appeal whether or not the plan makes an adverse decision on the appeal. The timeframes for providing a notice of decision on appeal generally start when a written appeal is received by the plan. Notice of decision on appeal may be provided in writing through in-hand, mail, or electronic delivery. Urgent care decisions may be delivered by telephone, fax, or other expeditious methods. Note, "days" means calendar (not business) days. The timeframes for providing a notice of decision on appeal are as follows:

• Urgent Care Appeals: As soon as possible considering the medical urgency, no later than 72 hours after the plan receives the participant's appeal.
• Pre-service Appeals: Within a reasonable period of time appropriate to the medical circumstances, no later than 30 days after the plan receives participant's appeal.
• Post-service Appeals: Within a reasonable period of time appropriate to the medical circumstances, no later than 60 days after the plan receives participant's appeal.

Upon request and free of charge, the participant has a right to reasonable access to and copies of all documents, records, and other information relevant to the plan's denial of a claim. Information is "relevant" information if it:

• Was relied upon in making the decision on participant's claim;
• Was submitted to, considered by, or generated by the plan in considering participant's claim; or
• In the case of a group health plan or a plan providing disability benefits, constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant’s diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.   

The participant is also entitled access to, and a copy of, any internal rule, guideline, protocol, or other similar criteria used as a basis for a decision on participant's denied claim upon request, free of charge. Similarly, if participant's claim is denied based on a determination involving a medical judgment, the participant is entitled to an explanation of the scientific or clinical reasons for that determination free of charge upon request. (A medical judgment includes whether a treatment, drug or other item is experimental, investigational or not medically necessary or appropriate.) In addition, if voluntary appeals or alternative dispute resolution options are available under the plan, the participant is entitled to receive information about the procedures for using these alternatives.

The participant can read the ERISA Rights Statement for information on actions to take if the participant feels his or her rights to a benefit have been improperly denied.