The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
For Pre-Service and Urgent Claims only, you will receive notice for approved claims as well as
denied claims.
Special Rules for Concurrent Claims (Medical)
Concurrent claims are claims that relate to a previously approved period of time or number of
treatments for an ongoing course of medical treatment.
If you request an extension of a previously approved period of time or number of treatments and
your claim involves urgent care, the Claims Administrator will decide your claim and notify you
of its decision within 24 hours after receipt of your request; provided your claim is filed at least
24 hours prior to the end of the approved time period or number of treatments. If you did not file
the claim at least 24 hours prior to the end of the approved treatment, the claim will be treated as
and decided within the timeframes for an Urgent Claim as described under “Initial Claim
Determination” earlier in this section. If your claim does not involve urgent care, then the time
periods for deciding pre-service claims and post-service claims, as applicable, will govern.
If there is a reduction in or termination of the ongoing course of treatment for which you have
received prior approval (for reasons other than amendment or termination of the plan), the
Claims Administrator will notify you. This reduction or termination of an ongoing course of
treatment will be considered an adverse benefit determination. You will receive notice in
advance of the date the reduction or termination will occur so that you have a sufficient
opportunity to appeal the decision before the reduction or termination occurs. If you appeal the
reduction or termination of your ongoing course of treatment, the reduction or termination will
not occur before a final decision is made on your appeal. If you disagree with the reduction or
termination, you should follow the procedures described previously for requesting a review of an
adverse benefit determination. The time periods that will apply to your request will depend on
the nature of your concurrent claim (e.g., urgent vs. pre-service vs. post-service).
Special Rules for Claims Related to Rescissions
A rescission is a discontinuation of coverage with retroactive effect. Coverage may be rescinded
because the individual or the person seeking coverage on behalf of the individual commits fraud
or makes an intentional misrepresentation of material fact, as prohibited by the terms of the plan.
However, some retroactive cancellations of coverage are not rescissions. Rescissions do not
include retroactive cancellations of coverage for failure to pay required premiums or
contributions toward the cost of coverage on time. A prospective cancellation of coverage is not
a rescission. If your coverage is going to be rescinded, you will receive written notice 30 days
before the coverage will be cancelled. A rescission will be considered an adverse benefit
determination. You will then have the opportunity to appeal the rescission as described under
“Request for Review of Adverse Benefit Determinations” earlier in this section. Internal request
for review of rescission denials should be submitted to, and will be decided by, the U.S. Bank
Benefit Claim Subcommittee. For purposes of rescissions, the U.S. Bank Benefit Claim
Subcommittee will be the Claims Administrator.
External Appeal Process
If, upon review, your claim is still denied and you disagree with the Claims Administrator's
decision, you may submit your claim to the external appeal process described below if your
claim denial involves either medical judgment or a recission. Other types of claim denials are not
eligible for external appeal. This step is not mandatory.
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