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Circumstances for filing claim |
One of the following conditions must be met:
· requirement to receive the benefit or
· reimbursement level depends upon approval |
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Who may file a claim |
Member or authorized representative |
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How to file a claim |
Follow instructions in the plan handbook very carefully and completely. |
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Time limit for plan to respond |
No later than 15 days of receipt of claim; plan may take a 15-day extension |
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Time limit for plan to request for additional information |
5 days from receipt of request |
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Time limit for claimant to provide information |
Not less than 45 days from receipt of plan's request for more information |
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Time limit for plan's response to completed claim |
Not later than 15 days, unless plan has taken an extension or claimant needs to provide additional information |
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How plan must notify claimant of denial |
Electronically or in writing |
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What plan must provide if claim is denied, whether wholly or partially |
· specific reason for denial
· reference to specific plan provision as basis for decision
· description of and explanation of additional material or information to complete claim
· description of the plan's review procedures and time limits for appealing claim denial
· statement of claimant's right to bring civil action under 502(a) after completing plan's internal review
Claimant may request and receive at no charge
· copy of any internal rule, guideline, protocol, or similar criterion considered in making decision and/or
· explanation of the scientific or clinical judgment for the determination if decision is based on medical necessity or experimental exclusion |
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Time limit for appealing a denial |
Within 180 days of receipt of denial |
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How claimant may submit appeal |
In writing |
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Plan obligation in considering an appeal |
· Provide, free of charge of charge, access to and copies of all information relevant to the claim
· Take into account all information submitted by the claimant, even if the information was not included in the original claim.
· have the review conducted by someone other than the original decision maker who is not a subordinate of that decision maker
· Ensure that the initial denial will not be given undue weight in the reconsideration
· Identify experts who provided advice, regardless of whether it was taken.
· In appeals based in whole or in part on a medical judgment, including possible experimental treatment, assure that the reviewer is a health care professional with appropriate training and experience.
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Time limits and notification mechanism for response to appeal |
Not later than 30 days after receipt of appeal. If plan has two levels of appeal, both must completed within the 30 days. Notification must be in writing or electronic. |
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What plans must provide if appeal is denied |
· the specific reason for the denial
· reference to the relevant plan provision
· statement that the claimant can receive free of charge all relevant information
· description of any voluntary appeal procedures the plan offer
· a statement of the member's right to bring a civil action
· notification that voluntary alternative dispute resolution options may be available and that more information is available from the U.S. Department of Labor or the state agency that regulates insurance.
Claimant may request and receive at no charge
· copy of any internal rule, guideline, protocol, or similar criterion considered in making decision and/or
explanation of the scientific or clinical judgment if decision is based on medical necessity or experimental treatment |
