Timing for Initial Benefit Determination
For all ERISA Plans, the law allows a reasonable amount
of time for the Claim Administrator to evaluate a claim
and decide whether to pay benefits based on the information
contained in the claim. Under the ERISA Claims and
Appeals rules, these times are dictated by what type of
claim is being considered and whether you followed the
proper procedures, as described in this section. The claims
procedures for medical, mental health and substance abuse
and prescription medication benefits will vary depending
on whether your claim is for an Urgent Care, Non-Urgent
Pre-Service, a Concurrent Care or a Post-Service Claim.
Read each section carefully to determine which procedure
is applicable to your request for benefits.
