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If you receive an adverse benefit determination
If your claim for a benefit is denied in whole or in part, you will receive a written notice that will provide:
  • The specific reason or reasons for the adverse benefit determination
  • Reference to specific plan provisions on which the determination was based
  • A description of any additional material or information necessary to complete the claim and an explanation of why such material or information is necessary
  • A description of the steps you must follow (including applicable time limits) if you want to appeal the adverse benefit determination of your claim, including:
    • Your right to submit written comments and have them considered
    • Your right to receive (upon request and free of charge) reasonable access to, and copies of, all documents, records and other information relevant to your claim
    • Your right to bring a civil action under Section 502 of ERISA if your claim is denied on appeal
  • If an internal rule, guideline, protocol or other similar criterion was relied on in denying your claim, either:
    • A description of the specific rule, guideline, protocol or criterion relied on
    • A statement that a copy of such rule, guideline, protocol or criterion will be provided free of charge upon request
  • If the basis for the adverse benefit determination was a determination of experimental or investigational treatment or similar exclusion or limit, either:
    • An explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to your circumstances
    • A statement that such an explanation will be provided free of charge upon request
  • In the case of an adverse benefit determination of an urgent care claim, a description of the expedited review process applicable to such claim.
Keep in mind, if you file an appeal, you are responsible for any expenses you incur pursuing the appeal. The plan does not cover appeal expenses.