Notice of Decision
You will be provided with written notice of the decision on
your claim. If your claim is denied (whether in whole or in
part), this notice will state:
- The specific reason for the determination;
- Reference to the specific Plan provision(s) on which
the determination is based;
- A description of any additional material or information
necessary to perfect the claim, and an explanation
of why the material or information is necessary;
- A description of the appeals procedures (including
voluntary appeals, if any) and applicable time limits;
- A statement of your right to bring a civil action under
ERISA Section 502(a) following an adverse benefit
determination on review;
- If an internal rule, guideline or protocol was relied
upon in deciding your claim, you will receive either a
copy of the rule or a statement that it is available upon
request at no charge;
- If the determination was based on the absence of
medical necessity, or because the treatment was
experimental or investigational, or other similar
exclusion, you will receive an explanation of the
scientific or clinical basis for the determination
applying the terms of the Plan to your claim, or a
statement that it is available upon request at no
charge; and
- For Urgent Care Claims, the notice will describe the
expedited review process applicable to Urgent Care
Claims. For Urgent Care Claims, the required determination
may be provided orally and followed with
written notifications.
Note
For Urgent Care Claims and Non-Urgent Pre-Service Claims, you will receive notice
of the care that will be covered by the Plan.
