If your claim is denied (in whole or in part) by the claims administrator, you will receive written notice from the claims administrator. The time for notifying you of a denied claim and the deadline for requesting an appeal will depend on the type of claim you have submitted.

Post-Service Claims. If a post-service claim for benefits is denied, the claims administrator will notify you no later than 30 days after the receipt of the claim. This 30-day period may be extended for an additional 15 days if the claims administrator determines the extension is necessary due to matters beyond the control of the plan and notifies you of the extension before the end of the initial 30-day period. If you have not furnished information that is necessary for determining your claim, the claims administrator will notify you and describe the information that is needed. You will be given a reasonable period of time, but not less than 45 days, in which to supply the missing information. While the claims administrator is waiting for the missing information, the deadline for responding to your claim will automatically be extended until 15 days after you furnish the missing information or, if you do not furnish the missing information, until 15 days after the date for furnishing such information.

If a post-service claim is denied by the claims administrator, you will have 180 days to file an appeal of the denial.

Pre-Service Claims. The claims administrator will notify you of its determination with respect to a pre-service claim, whether adverse or not, no later than 15 days after the receipt of the claim. This 15-day period may be extended for an additional 15 days if the claims administrator determines the extension is necessary due to matters beyond the control of the plan and notifies you of the extension before the end of the initial 15-day period. If you have not furnished information that is necessary for determining your claim, the claims administrator will notify you no later than five days after receiving your claim and will describe the information that is needed. You will be given a reasonable period of time, but not less than 45 days, in which to supply the missing information. While the claims administrator is waiting for the missing information, the deadline for responding to your claim will automatically be extended until 15 days after you furnish the missing information or, if you do not furnish the missing information, until 15 days after the date for furnishing such information.

If a pre-service claim is denied by the claims administrator, you will have 180 days to file an appeal of the denial.

Urgent Care Claims. The claims administrator will notify you with respect to an urgent care claim, whether adverse or not, as soon as possible, but no later than 72 hours after the receipt of the claim. If you have not furnished information that is necessary for determining your claim, the claims administrator will notify you within 24 hours of receiving your claim and will describe the information that is needed. You will be given a reasonable period of time, but not less than 48 hours, in which to supply the missing information. While the claims administrator is waiting for the missing information, the deadline for responding to your claim will automatically be extended until 48 hours after you furnish the missing information or, if you do not furnish the missing information, until 48 hours after the time for furnishing such information has expired.

If an urgent care claim is denied by the claims administrator, you will have 180 days to file an appeal of the denial.

Concurrent Care Claim. If the plan has approved a course of treatment to be provided over a period of time or a number of treatments and reduces or terminates the course of treatment before the expiration of the period of time or number of treatments that was approved, such reduction or termination will be treated as the denial of a concurrent care claim. The claims administrator will notify you of the denial of the concurrent care claim in sufficient time before the reduction or termination of treatment to allow you to appeal the denial. If you are receiving an ongoing course of treatment, you may proceed with an expedited external review at the same time the internal appeals process is in progress.

In addition, if you request the claims administrator to extend a course of treatment beyond the approved period of time or course of treatment, and your claim involves urgent care (as defined above), the claims administrator will notify you of its decision within 24 hours of receiving your claim, provided you made your claim at least 24 hours before the course of treatment was scheduled to terminate. If your claim involves urgent care and is made less than 24 hours before the course of treatment was scheduled to terminate, your claim will be treated as an urgent care claim.

If a claim for benefits is denied, you will be notified in writing, and the written notice will contain the following information:

If your claim for benefits is denied, you may not bring a lawsuit to recover the denied benefits until you have exercised all of your appeal rights and your appeal has been denied in whole or part. The plan administrator is granted the discretion to determine all claims for eligibility for all fully insured benefits, and for all self-insured benefits, the discretion to determine all claims for eligibility, benefits and all rights under this plan in its sole discretion.

If you wish to appeal the denial of a claim for benefits (including a retroactive termination of coverage) under the plan, you or your authorized representative must file written notice of the appeal before the time for filing the appeal expires. Your appeal must be filed with the appropriate appeals administrator. The appeals administrator is:

Your written notice should state in reasonable detail all of the grounds upon which your appeal is based, including references to applicable plan provisions, and any issues or comments you feel are relevant to your claim. You should supply any documents, records or other information relating to your claim. You may also request copies of documents, records and other information relevant to your claim that are in the possession of the plan, which will be provided to you free of charge. In addition, you shall receive, free of charge, any new or additional evidence considered, relied upon or generated by the plan in connection with your claim or any new or additional rationale upon which the decision of your claim is based, as soon as possible and sufficiently in advance of the date on which the final appeals decision is required to be provided to you so as to give you a reasonable opportunity to respond prior to that date.

The appeals administrator will review the denial of your claim without deference to the decision of the claims administrator. If the denial of your claim was based, in whole or in part, on a medical judgment, the appeals administrator will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who did not participate in the denial of your claim (and is not the subordinate of a health care professional who did participate in the claim denial).

The appeals administrator will also identify the medical or vocational experts whose advice was obtained on behalf of the plan in denying your claim, without regard to whether the plan relied on such advice. Finally, if the claim that was denied was an urgent care claim, the appeals administrator will permit an expedited appeal in which the appeal may be made orally and all necessary information, including the appeals administrator decision on appeal, may be transmitted between you and the plan by telephone, facsimile or other similar expeditious method.

The applicable time limits to file an appeal of a benefit denial are set forth below:

If your appeal is denied, you will be notified in writing, and the written notice will contain the following information: