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.