If you receive an Adverse Benefit Determination, you have 180 days following receipt
of the notification in which to appeal the decision. In order to appeal, you
must request in writing from the Plan Administrator or Claims Administrator a review
of the claim. Your written request must include: the name of the Subscriber,
his or her Social Security number, the name of the patient, the Group Plan Number,
and in clear and concise terms the reason or reasons for the appeal. You may
submit written comments, documents, records, and other information relating to the
Claim. Notification of the Review Determination will be made within 60 days
of your request.
If you receive an Adverse Benefit Determination, you are entitled to receive, upon
written request and free of charge, reasonable access to, and copies of all documents,
records, and other information relevant to the Claim.
If an Adverse Benefit Determination was based on an internal rule, guideline, protocol
or other similar criterion you are entitled to receive, upon written request and
free of charge, the specific rule, guideline, protocol or criterion.
If an Adverse Benefit Determination was based on Medical Necessity or Experimental
or Investigational treatment or similar exclusion or limit, you are entitled to
receive, upon written request and free of charge, an explanation of the scientific
or clinical judgment for the determination.
You have the right to bring a civil action under section 502 of ERISA following
an Adverse Benefit Determination on review. If your plan provides a voluntary
arbitration/appeals procedure, you are entitled to receive, upon written request
and free of charge, sufficient information about the voluntary appeal to enable
you to make an informed judgment about whether to submit a benefit dispute to the
voluntary level of appeal.
The Plan Document shall prevail should the above statement conflict with any provision
contained within the Plan Document.
Any person who knowingly presents a false or fraudulent claim is guilty of a crime
and may be subject to fines and confinement in prison. Carefully review the information
presented on this document. If you detect potential fraudulent activities, please
call our fraud hotline at:
1-800-966-7247 or e-mail us at: firstname.lastname@example.org