APPEALING UNREIMBURSED CLAIMS

APPEALING AN UNREIMBURSED PRE-SERVICE CLAIM

If a medical, prescription, dental or vision claim is denied in whole or in part, the Covered Person shall receive written notification of the Adverse Benefit Determination. A claim denial is provided by the appropriate Plan showing: 

1. The reason the claim was denied;

2. Reference(s) to the specific Medical Plan, Prescription Drug Plan, Dental Plan or Vision Plan provision(s) or rule(s) upon which the decision was based which resulted in the Adverse Benefit Determination;

3. Any additional information needed to perfect the claim and why such information is needed; and

4. An explanation of the Covered Person’s right to appeal the Adverse Benefit Determination for a full and fair review and the right to bring a civil action following an Adverse Benefit Determination on appeal.  

If a Covered Person does not understand the reason for any Adverse Benefit Determination, the Covered Person may contact the appropriate Plan Supervisor at the address or telephone number shown on the claim denial. 

The Covered Person shall appeal the Adverse Benefit Determination before the Covered Person may exercise the Covered Person’s right to bring a civil action. This Plan provides two (2) levels of benefit determination review and the Covered Person shall exercise both levels of review before bringing a civil action.

To initiate the first level of benefit review, the Covered Person shall submit in writing an appeal or a request for review of the Adverse Benefit Determination to the appropriate Plan Supervisor within one hundred eighty (180) days after the Adverse Benefit Determination. The Covered Person shall include any additional information supporting the appeal or the information required by the Medical Plan, Prescription Drug Plan, Dental Plan or Vision Plan which was not initially provided and forward it to the appropriate Plan Supervisor within the 180-day time period. Failure to appeal the Adverse Benefit Determination within the 180-day time period renders the determination final. Any appeal received after the 180-day time period has expired receives no further consideration.

Appeals or requests for review of Adverse Benefit Determinations must be submitted to the appropriate Plan Supervisor in writing. Supporting materials may be submitted via mail, electronic claims submission process, facsimile (fax) or electronic mail (e-mail):

The first level of benefit determination review is completed by the Medical, Prescription Drug, Dental or Vision Plan Supervisor. The appropriate Plan Supervisor researches the information initially received and determines if the initial determination was appropriate based on the terms and conditions of the appropriate Plan and other relevant information. Notice of the decision on the first level of review must be sent to the Covered Person within fifteen (15) days following the date the appropriate Plan Supervisor receives the request for reconsideration.

If, based on the Plan Supervisor’s review, the initial Adverse Benefit Determination remains the same and the Covered Person does not agree with that benefit determination, the Covered Person may initiate the second level of benefit review. The Covered Person shall request the second review in writing and send it to the appropriate Plan Supervisor, not later than sixty (60) days after receipt of the Plan Supervisor’s decision from the first level of review. Failure to initiate the second level of benefit review within the 60-day time period renders the determination final.

The Plan Administrator reviews the claim in question along with the additional information submitted by the Covered Person. The Plan Administrator, who is neither the original decision maker nor the decision maker’s subordinate, conducts a full and fair review of the claim. The Plan Administrator may not give deference to the initial benefit determination. The Plan Administrator may, when appropriate or if required by law, consult with relevant health care, prescription drug care, dental care or vision care professionals in making decisions about appeals that involve specialized medical, dental or vision care judgment. Where the appeal involves issues of Medical or Dental Necessity or experimental treatment, the Plan Administrator shall consult with a health care, prescription drug care, dental care or vision care professional with appropriate training who was neither the medical nor dental care professional consulted in the initial determination or his or her subordinate.

After a full and fair review of the Covered Person’s appeal, the Plan Administrator shall provide a written or electronic notice of the final benefit determination containing the same information as notices for the initial determination within fifteen (15) days.

If more time or information is needed to make a determination for a pre-service or post-service appeal, the Plan Supervisor will provide notice in writing to request an extension of up to fifteen (15) days and to specify any additional information needed to complete the review.

In the event any new or additional information is considered, relied upon or generated in connection with the appeal, the Plan will provide this information to the Covered Person as soon as possible, free of charge and sufficiently in advance of the decision, so that the Covered Person will have an opportunity to respond. Also, if any new or additional rationale is considered for a denial it will be provided to the Covered Person as soon as possible and sufficiently in advance of the decision to allow a reasonable opportunity to respond.

If an appeal decision is not made and issued within the time period described above, or if the Plan fails to meet any of the requirements of this appeal process, the Covered Person may deem the appeal to be exhausted and proceed to the external review or bring a civil action. The Covered Person should contact the Plan Administrator to ask for confirmation that the Covered Person’s appeal has been denied, or to request an External Review.

INDEPENDENT EXTERNAL REVIEW FOR A PRE-SERVICE CLAIM

Does not apply to dental or vision claims.

After exhaustion of all appeal rights stated above, a Covered Person may also request a final independent external review of any Adverse Benefit Determination involving a question of Medical Necessity or other issue requiring medical expertise for resolution.

To assert this right to independent external medical review, the Covered Person shall request such review in writing within one hundred twenty (120) days after a decision is made upon the second level benefit determination above.

If an independent external review is requested, the Plan Administrator through the Medical Plan Supervisor shall forward the entire record on appeal, within ten (10) days, to an independent external review organization (IRO) selected randomly. The IRO shall notify the Covered Person of its procedures to submit further information.

The IRO shall issue a final decision within forty-five (45) days after receipt of all necessary information.

The decision of the IRO is final and binding except that the Covered Person has the right to appeal the matter to a court with jurisdiction.

APPEALING AN UNREIMBURSED POST-SERVICE CLAIM

If a medical, prescription, dental or vision claim is denied in whole or in part, the Covered Person shall receive written notification of the Adverse Benefit Determination. A claim Explanation of Benefits (EOB) is provided by the Plan Administrator through the appropriate Plan Supervisor showing: 

1. The reason the claim was denied;

2. Reference(s) to the specific Medical Plan, Prescription Drug Plan, Dental Plan or Vision Plan provision(s) or rule(s) upon which the decision was based which resulted in the Adverse Benefit Determination;

3. Any additional information needed to perfect the claim and why such information is needed; and

4. An explanation of the Covered Person’s right to appeal the Adverse Benefit Determination for a full and fair review and the right to bring a civil action following an Adverse Benefit Determination on appeal. 

If a Covered Person does not understand the reason for any Adverse Benefit Determination, he or she should contact the appropriate Plan Supervisor at the address or telephone number shown on the EOB form. 

The Covered Person must appeal the Adverse Benefit Determination before the Covered Person may exercise his or her right to bring a civil action. This Plan provides two (2) levels of benefit determination review and the Covered Person must exercise both levels of review before bringing a civil action.

To initiate the first level of benefit review, the Covered Person must submit in writing an appeal or a request for review of the Adverse Benefit Determination to the appropriate Plan Supervisor within one hundred eighty (180) days after the Adverse Benefit Determination. The Covered Person should include any additional information supporting the appeal or the information required by the Medical Plan, Prescription Drug Plan, Dental Plan or Vision Plan which was not initially provided and forward it to the appropriate Plan Supervisor within the 180-day time period. Failure to appeal the Adverse Benefit Determination within the 180-day time period will render the determination final. Any appeal received after the 180-day time period has expired will receive no further consideration. 

Appeals or requests for review of Adverse Benefit Determinations must be submitted to the appropriate Plan Supervisor in writing. Supporting materials may be submitted via mail, electronic claims submission process, facsimile (fax) or electronic mail (e-mail):

1. First Level of Benefit Determination Review

The first level of benefit determination review is completed by the Medical, Prescription Drug, Dental or Vision Plan Supervisor. The appropriate Plan Supervisor researches the information initially received and determines if the initial determination was appropriate based on the terms and conditions of the appropriate Plan and other relevant information. Notice of the decision on the first level of review is sent to the Covered Person within thirty (30) days following the date the appropriate Plan Supervisor receives the request for reconsideration.

If, based on the Plan Supervisor’s review, the initial Adverse Benefit Determination remains the same and the Covered Person does not agree with that benefit determination, the Covered Person must initiate the second level of benefit review. The Covered Person must request the second review in writing and send it to the appropriate Plan Supervisor, not later than sixty (60) days after receipt of the Plan Supervisor’s decision from the first level of review. Failure to initiate the second level of benefit review within the 60-day time period will render the determination final. 

2. Second Level of Benefit Determination Review

The Plan Administrator reviews the claim in question along with the additional information submitted by the Covered Person. The Plan Administrator, who is neither the original decision maker nor the decision maker’s subordinate, conducts a full and fair review of the claim. The Plan Administrator may not give deference to the initial benefit determination. The Plan Administrator may, when appropriate or if required by law, consult with relevant health care, prescription drug care, dental care or vision care professionals in making decisions about appeals that involve specialized medical, dental or vision care judgment. Where the appeal involves issues of Medical or Dental Necessity or experimental treatment, the Plan Administrator shall consult with a health care, prescription drug care, dental care or vision care professional with appropriate training who was neither the medical nor dental care professional consulted in the initial determination or his or her subordinate.

After a full and fair review of the Covered Person’s appeal, the Plan Administrator shall provide a written or electronic notice of the final benefit determination within a reasonable time, but no later than thirty (30) days from the date the appeal is received by the Plan Administrator at each level of review.

All claim payments are based upon the terms contained in the Wrap Plan Document and Summary Plan Descriptions, on file with the Plan Administrator and the appropriate Plan Supervisor. The Covered Person may request, free of charge, more detailed information, names of any medical, prescription drug, dental or vision care professionals consulted and copies of relevant documents, as defined in and required by law, which were used by the Plan Administrator to adjudicate the claim.

If more time or information is needed to make a determination for a pre-service or post-service appeal, the Plan Supervisor will provide notice in writing to request an extension of up to fifteen (15) days and to specify any additional information needed to complete the review.

In the event any new or additional information is considered, relied upon or generated in connection with the appeal, the Plan will provide this information to the Covered Person as soon as possible, free of charge and sufficiently in advance of the decision, so that the Covered Person will have an opportunity to respond. Also, if any new or additional rationale is considered for a denial it will be provided to the Covered Person as soon as possible and sufficiently in advance of the decision to allow a reasonable opportunity to respond.

If an appeal decision is not made and issued within the time period described above, or if the Plan fails to meet any of the requirements of this appeal process, the Covered Person may deem the appeal to be exhausted and proceed to the external review or bring a civil action. The Covered Person should contact the Plan Administrator to ask for confirmation that the Covered Person’s appeal has been denied, or to request an External Review.

INDEPENDENT EXTERNAL REVIEW FOR A POST-SERVICE CLAIM

Does not apply to dental or vision claims.

After exhaustion of all appeal rights stated above, a Covered Person may also request a final independent external review of any Adverse Benefit Determination involving a question of Medical Necessity, or other issue requiring medical expertise for resolution.

To assert this right to independent external medical review, the Covered Person shall request such review in writing within one hundred twenty (120) days after a decision is made upon the second level benefit determination above.

If an independent external review is requested, the Plan Administrator through the Medical Plan Supervisor shall forward the entire record on appeal, within ten (10) days, to an independent external review organization (IRO) selected randomly. The IRO notifies the Covered Person of its procedures to submit further information.

The IRO issues a final decision within forty-five (45) days after receipt of all necessary information.

The decision of the IRO is final and binding except that the Covered Person has an additional right to appeal the matter to a court with jurisdiction.