The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
In most circumstances, before you may submit your claim to the external appeal process, you
must first follow the claims procedures outlined above by filing an initial claim and a request for
review of an adverse benefit determination with your Claims Administrator. However, in certain
circumstances (described below), you may receive an expedited external review. In this case, you
may not have to exhaust the internal claims process before filing a request for external review.
Within four months of the date you receive notice that, upon review, your claim continues to be
denied, you may submit your claim to the external appeal process by writing to your Claims
Administrator.
Your written external appeal 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.
Under the following circumstances, you can request an expedited external review:
• If you have received an initial claim determination that denied your claim, you may request
expedited external review if (1) you filed a request for an Urgent Care appeal AND (2) the
time for completing the internal review process would seriously jeopardize life, health, or
ability to regain maximum function.
• If you appealed your initial claim denial and received a final internal claim denial and (1) the
time for completing the external review process would seriously jeopardize life, health, or
ability to regain maximum function OR (2) the denial of the internal appeal concerned the
admission, availability of care, continued stay, or health care item or service for which you
received emergency services, but you have not been discharged from a facility.
Preliminary Review of Standard (Not Expedited) External Claims
Within five days of receipt of the external review request, your Claims Administrator will
complete a preliminary review of your request to determine if your claim is eligible for external
review. Your claim is eligible for external review if:
• you are or were covered under plan when the item or service was requested or provided,
• the claim or appeal denial does not relate to your failure to meet the plan’s eligibility
requirements,
• you have exhausted the internal appeal process (unless you are not required to exhaust the
internal claims procedures), and
• you have provided all information and forms required to process external review.
Within one business day after completion of the preliminary review, your Claims Administrator
will notify you in writing regarding whether your claim is eligible for external review. If your
request was not complete, the notice will describe information or materials needed to complete
request. You will have until the end of the four month period you had to file a request for an
external review or 48 hours (whichever is later) to complete your request. If your request is
complete but not initially eligible for external review, the notice will include the reasons your
request was ineligible and contact information for the Employee Benefits Security
Administration.
External Review Process
If your Claims Administrator determines your claim is initially eligible for external review, your
claim will be assigned to an independent review organization. The independent review
organization will notify you that your claim is initially eligible for external review and that the
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