The eligibility and enrollment rules for the U

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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 116
Retiree Health Care SPD Effective January 1, 2012 review process is beginning. The notice will also inform you that you have 10 business days following receipt of the notice to provide additional information to the independent review organization for it to consider. If however, the independent review organization determines that your claim does not involve either medical judgment or a rescission, it will notify you that the claim is not eligible for external review. If your claim is eligible, the independent review organization will not defer to the decisions made during the internal review process and will look at your claim anew. The independent review organization will consider all the information and documents that it receives in a timely manner when making its decision. The independent review organization and/or your Claims Administrator will provide written notice of the final external review decision within 45 days after it receives the request for external review. If the independent review organization reverses the Claims Administrator’s denial of your claim, the decision will be binding on the plan, and the plan must immediately provide coverage or payment, regardless of whether it intends to seek judicial review of the external review decision and unless or until there is a judicial decision otherwise. Expedited External Review Process In general, the same rules that apply to standard external review apply to expedited external review, except that the timeframe for decisions and notifications is shorter. Expedited Preliminary Review: Your Claims Administrator will immediately conduct a preliminary review to determine if your claim is initially eligible for external review. After the preliminary review is completed your Claims Administrator will immediately notify you of its determination. If your request was not complete, the notice will describe information or materials needed to complete the 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. Expedited External Review: If your claim is initially eligible for expedited external review, your claim will be assigned to an independent review organization. The independent review organization will provide you its final decision as expeditiously as your medical condition or circumstances require, but in no event will the notification be provided later than 72 hours after the independent review organization receives the request for expedited external review. If the notice of the decision is not provided in writing, then the independent review organization must provide you with written confirmation of the decision within 48 hours after the notice of decision was first provided to you by other means. The period during which your external appeal is brought and decided will not count against the time period permitted for you to bring a lawsuit (i.e., any applicable statute of limitations will be tolled). Submitting your claim to the external appeal process is not a prerequisite and does not prevent you from filing a civil action under section 502(a) of ERISA once the claim-and-review procedure has been completed. Failure to Strictly Adhere to Internal Claims and Appeals Process Effective January 1, 2012, (or a later date if the compliance deadline is further extended), if the Claims Administrator fails to strictly adhere to the internal ERISA claims procedures described 117
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The eligibility and enrollment rules for the U

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