The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 Type of Claim Post-Service Claims Pre-Service Claims Urgent Claims Deadline for Notifying Claimant of Initial Claim Determination 30 days after receipt of the initial claim 15 days after receipt of the initial claim INCORRECTLY FILED CLAIMS 5 days from the date the incorrect claim was received by a person regularly responsible for handling claims No later than 72 hours after receipt of initial claim, taking into account the medical urgency Extensions to Deadline for Notifying Claimant of Initial Claim Determination 15-day extension available 15-day extension available COMPLETE CLAIMS NOT APPLICABLE INCOMPLETE CLAIMS 48 hours after earlier of: • the date claimant provides requested information; or • the end of 48 hour period for claimant to provide requested information Time Period, if any, for Claimant to Provide Additional Information 60 days after claimant receives notice of need for additional information 60 days after claimant receives notice of need for additional information 48 hours from the time claimant receives notice of an incomplete claim If your claim is denied, in whole or in part, you will receive a written notice, which includes: • information about your claim and the reason(s) for the denial; • the plan or Program provisions on which the denial is based; • a description of additional material (if any) needed to perfect the claim; • an explanation of your right to request a review; • a statement of your right to file a civil action under section 502(a) of ERISA if your claim is denied upon a request for review; • a statement indicating whether an internal rule, guideline, protocol or other similar criterion was relied on in deciding your claim and information explaining your right to request such information, free of charge; • if an adverse benefit determination is based on medical necessity or experimental treatment or a similar exclusion or limitation, an explanation of the scientific or clinical judgment for the determination applied to the your medical circumstances; • for Urgent Claims only, a description of the expedited review process applicable to such claims; • description of the plan’s standard, if any, used in denying the claim (e.g., if a medical necessity standard is used to deny the claim, the notice must describe the medical necessity standard); • description of available internal appeals and external review processes; and 112
Retiree Health Care SPD Effective January 1, 2012 • disclosure of availability of and contact information for any applicable office or health insurance consumer assistance or ombudsman, if any, established by the Department of Health and Human Services to assist in internal claims, appeals and external review process. For Pre-Service and Urgent Claims only, you will receive notice for approved claims as well as denied claims. If Your Claim is Denied If a claim for benefits is denied in whole or in part, you may call the Claims Administrator at the number on your ID card before requesting a formal appeal. If the Claims Administrator cannot resolve the issue to your satisfaction over the phone, you have the right to file a formal appeal as described below. Calling the Claims Administrator alone will not start the formal appeal process. Request for Review of Adverse Benefit Determinations If your initial claim is denied in whole or in part and you disagree with the decision, you may request that the decision or adverse benefit determination be reviewed. An adverse benefit determination is defined as (a) a denial, reduction, or termination of benefits, or (b) a failure to provide or make payment (in whole or in part) for a benefit. (A rescission of coverage is also an adverse benefit determination. Please see “Special Rules for Claims Related to Rescissions” later in this section for information on how to appeal a rescission.) Within 180 days of the date you receive an adverse benefit determination with which you disagree, you should submit a request for review to your Claims Administrator. With the exception of Urgent Claims, all requests for review should be submitted in writing. Requests for review of adverse benefit determinations relating to Urgent Claims may be made either orally or in writing. Your request for review may (but is not required to) include issues, comments, documents, records, and other information relating to your claim that you want considered in reviewing your claim. You may request reasonable access to, and copies of, all documents, records, and other information relevant to your adverse benefit determination without charge. In reviewing your claim, your Claims Administrator will ensure that your claim is reviewed by individuals who were not involved in the initial adverse benefit determination. The Claims Administrator will not defer to the initial claim reviewer's decision and will look at your claim anew. If your adverse benefit determination was based upon medical judgment, a health care professional with the appropriate training and experience in the field of medicine involved in the medical judgment will be consulted during the review of your claim. The health care professionals will not have been involved in the initial adverse benefit determination (nor a subordinate of any person previously consulted). You may request information regarding the identity of any health care professional whose advice was obtained during the review of your claim. If the Claims Administrator considers, relies on or generates new or additional evidence in connection with its review of your claim, you will be provided the new or additional evidence free of charge as soon as possible and with enough time before a final determination is required to be provided to you (see the chart under “Determination Upon Request for Review” below) so that you will have an opportunity to respond. If the Claims Administrator relies on a new or additional rationale in denying your claim on review, you will be provided with the new or 113
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