Claims Administrator and Fiduciary

Information Pertaining to the Filing of an Appeal of an
Adverse Benefit Determination for a Health Claim.

The Appeal Process

With the exception of urgent care claims, you will have 180 days following receipt of an adverse benefit decision to appeal the decision. You will be notified of the decision not later than 30 days (for pre-service claims) or 60 days (for post-service claims) after the appeal is received. You may submit written comments, documents, records and other information relating to your claim, whether or not the comments, documents, records or information were submitted in connection with the initial claim. You may also request that the Plan provide you, free of charge, copies of all documents, records and other information relevant to the claim.

If your claim medical involves urgent care, an expedited appeal may be initiated by a telephone call to the Plan's Member Services number indicated on your Identification Card. You or your authorized representative may appeal urgent care claim denials either orally or in writing. All necessary information, including the appeal decision, will be communicated between you or your authorized representative and the Plan by telephone, facsimile, or other similar method. You will be notified of the decision not later than 72 hours after the appeal is received.