the specific reason(s) for your adverse benefit determination; reference to the specific Plan provision on which the determination is based; a description of any additional material or information necessary for you to fix your claim and an explanation of why such material or information is necessary; a description of the review procedures, including a statement of your right to bring a lawsuit following an adverse benefit determination on review; either the specific rule or guideline used in making your benefits determination or a statement that such a rule or guideline was relied upon in making the determination and that a copy of such rule or guideline will be provided free of charge upon request; if the adverse benefit determination is based on a medical judgment, either an explanation of such judgment, or a statement that such explanation will be provided to you free of charge upon request; and in the case of an Urgent Care Claim, a description of the expedited review process to which you may be entitled. In addition to the notice standards described above, to the extent required by the Affordable Care Act, all adverse benefit determination notices will include the following: (a) information identifying the claim involved, including the date of service, the health care provider, the claim amount, the diagnosis code, the treatment code, and the corresponding meaning of those codes; (b) the reason or reasons for the adverse benefit determination that includes the denial code and its corresponding meaning and a description of the standard, if any, that was used to deny the Plan’s claim (for notices of final internal adverse benefit determinations, the description will include a discussion of the decision); (c) a description of available internal appeals and external review processes, including how to initiate an appeal; and (d) contact information for any applicable office of health insurance consumer assistance or ombudsman established under the Affordable Care Act to assist individuals with the internal claims and appeals and external review processes. How to Appeal a Claim Decision If you disagree with a claim determination, you can contact the Plan Administrator in writing to formally request an appeal. If the appeal relates to a claim for payment, your request should include: The name and the identification number from the ID card. patient’s The date(s) of health care service(s). The provider’s name. The reason you believe the claim should be paid. Any documentation or other written information to support your request for claim payment.
the specific reason(s) for your adverse benefit determination; reference to the specific Plan provision on which the determination is based; a description of any additional material or information necessary for you to fix your claim and an explanation of why such material or information is necessary; a description of the review procedures, including a statement of your right to bring a lawsuit following an adverse benefit determination on review; either the specific rule or guideline used in making your benefits determination or a statement that such a rule or guideline was relied upon in making the determination and that a copy of such rule or guideline will be provided free of charge upon request; if the adverse benefit determination is based on a medical judgment, either an explanation of such judgment, or a statement that such explanation will be provided to you free of charge upon request; and in the case of an Urgent Care Claim, a description of the expedited review process to which you may be entitled. In addition to the notice standards described above, to the extent required by the Affordable Care Act, all adverse benefit determination notices will include the following: (a) information identifying the claim involved, including the date of service, the health care provider, the claim amount, the diagnosis code, the treatment code, and the corresponding meaning of those codes; (b) the reason or reasons for the adverse benefit determination that includes the denial code and its corresponding meaning and a description of the Plan’s standard, if any, that was used to deny the claim (for notices of final internal adverse benefit determinations, the description will include a discussion of the decision); (c) a description of available internal appeals and external review processes, including how to initiate an appeal; and (d) contact information for any applicable office of health insurance consumer assistance or ombudsman established under the Affordable Care Act to assist individuals with the internal claims and appeals and external review processes. How to Appeal a Claim Decision If you disagree with a claim determination, you can contact the Plan Administrator in writing to formally request an appeal. If the appeal relates to a claim for payment, your request should include: The patient’s name and the identification number from the ID card. The date(s) of health care service(s). The provider’s name. The reason you believe the claim should be paid. Any documentation or other written information to support your request for claim payment.
Wheaton-2018-Health-Welfare-SPD.docx