15.16.1 MEDICAL BENEFIT CLAIM DETERMINATIONS AND APPEALS The following procedures apply to any claim for medical benefits (including dental, vision and prescription drug). 15.16.1.1 Timing of Initial Determination – Precertification Medical Benefit Claims The Plan requires that you get prior review or approval before you receive certain covered services or treatments in order to receive higher levels of benefits under the Plan than if prior approval is not obtained. The following rules apply to these claims for prior review or approval required by the Plan, such as precertification claims for health care services under the Plan’s utilization management program or the prior authorization required for certain Prescription Drug Benefits. All prior review or approval procedures required by the Plan are referred to in these procedures as “precertification” claims. 15.16.1.1.1 Urgent precertification claims If your precertification claim is determined by the Plan to be a claim involving urgent care (as defined below), notice of the Plan’s decision will be provided to you no later than 72 hours after receipt of your claim by the Plan, unless you do not provide sufficient information to decide your claim. In that case, notice requesting specific additional information will be provided to you within 24 hours of receipt of your claim. The Plan’s decision regarding your claim will then be issued no later than 48 hours after the earlier of 1) the Plan’s receipt of the requested information or 2) the expiration of the time period set by the Plan for you to provide the requested information (at least 48 hours). Benefit denials may be oral or in writing. If the denial is provided orally, written notice will also be provided within 3 days after the oral notice. A “claim involving urgent care” is a claim for precertification where application of the normal time periods for deciding your claim 1) could seriously jeopardize your life or health or your ability to regain maximum function, or 2) in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot adequately be managed without the care or treatment being sought. If a physician with knowledge of your medical condition determines that your claim meets this definition of urgent care, the claim will be treated by the Plan as involving urgent care. 15.16.1.1.2 Regular precertification claims If your precertification claim is not an urgent care claim, written notice of the Plan’s decision will generally be provided to you within a reasonable period of time, but no later than 15 days after receipt of your claim by the Plan. If matters beyond the control of the Plan so require, one 15-day extension of time for processing the claim beyond the initial 15 days may be taken. Written notice of the extension will be furnished to you before the end of the initial 15-day period. An extension notice will explain the reasons for the extension and the expected date of a decision. If an extension is required because you have not provided the information necessary to decide your claim, the notice of extension will specifically describe the required information, and the time period for processing your claim will not run from the date of such notice until the earlier of 1) the date the Plan receives your response to a request for additional information or 2) the date set by the Plan for your requested response (at least 45 days from the date of the request). 15.16.1.1.3 Failure to follow precertification procedures If your communication to the Plan concerning precertification does not comply with the Plan’s procedures for filing pre-certification claims, notice of the proper procedures will be provided to you within five days of the communication. If, however, the communication involves urgent care, notice will be provided within 24 hours. Such corrective notice will be provided only if your communication specifically names the claimant, medical condition or symptoms, and the treatment, service or product being requested. Notice may be oral, unless you request written notice. 15.16.1.2 Timing of Initial Determination – Medical Benefit Claims After Service or Treatment If your claim for a benefit does not require pre-approval in advance of receiving medical care, written notice of a denial will generally be provided to you within a reasonable period of time, but no later than 30 days after receipt of your claim by the Plan. If matters beyond the control of the Plan so require, one 15-day extension of time for processing the claim beyond the initial 30 days may be taken. A written notice of the extension will be furnished to you before the end of the initial 30-day period. An extension notice will explain the reasons for the extension and the expected date of a decision. If an extension is required because you have not provided the information necessary to decide your claim, the notice of extension will specifically describe the required information, and the time period for processing your claim will not run from the date of such notice until the earlier of 1) the date the Plan receives your response to a request for additional information or 2) the date set by the Plan for your requested response (at least 45 days from the date of the request). 15.16.1.3 Timing of Determination – Concurrent Care Medical Decision 15.16.1.3.1 Reduction or termination of ongoing course of treatment If the Plan has previously approved an ongoing course of treatment to be provided over a period of time or a number of treatments, notice of any later decision to reduce or terminate the ongoing course of treatment (other than by Plan amendment or termination) shall be treated as an adverse benefit determination that you can appeal. Such notice will be provided to you sufficiently in advance of the reduction or termination to allow you to appeal and receive a determination on appeal before the treatment is reduced or terminated. 15.16.1.3.2 Extension of ongoing course of treatment involving urgent care If your request that the Plan extend an ongoing course of treatment beyond the previously approved period of time or number of treatments involves urgent care, you will be notified of the decision by the Plan within 24 hours after its receipt of the request, provided the request is received at least 24 hours prior to the expiration of the pre-approved period of time or number of treatments. 15.16.1.4 Contents of Initial Denial – Medical Benefit Claims If your claim is denied, in whole or in part, you will be notified in writing by the Plan. The written notice will include the following: the specific reason or reasons for the denial; references to the specific Plan provisions on which the denial is based; a description of any additional material or information necessary in order for you to perfect the claim, and an explanation of why such material or information is needed; an explanation of the Plan’s review procedure for denied claims, including the applicable time limits for submitting your claim for review (claims involving urgent care will have a description of expedited appeal procedures); a statement of your right to bring a civil action under Section 502(a) of ERISA if your claim is denied on appeal; a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in deciding your claim for benefits, or a statement that such was relied upon and a copy will be provided free of charge upon request; and if the decision was based on a medical necessity or experimental treatment or other similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying Plan terms to your medical circumstances, or a statement that an explanation will be provided free of charge upon request. 15.16.1.5 Appeal Procedure for Denied Claim If you wish to appeal a denial of a claim, you or your authorized representative must file a written appeal with the Plan Administrator within 180 days after receiving notice of denial, unless your claim concerns the reduction or termination of a previously approved ongoing course of treatment. In that case, you must file a written appeal within a shorter time period that permits the Plan Administrator to issue an appeal decision before the treatment is reduced or terminated. You or your authorized representative may submit a written statement, documents, records, and other information. You may also, free of charge upon request, have reasonable access to and copies of Relevant Documents. The review will consider all statements, documents, and other information submitted by you or your authorized representative, whether or not such information was submitted or considered under the initial denial decision. Claim determinations are made in accordance with Plan documents and, where appropriate, Plan provisions are applied consistently to similarly situated claimants. In addition: the appeal decision will not defer to the initial decision denying your claim and will be made by a plan fiduciary who is not a person who made the initial decision, nor a subordinate of such person; if the initial denial decision was based in whole or in part on a medical judgment, the plan fiduciary will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment; any health care professional engaged for such consultation will not be a person consulted in the initial decision, nor a subordinate of any such person; any medical or vocational expert whose advice was obtained in connection with the decision to deny your claim will be identified upon request, whether or not the advice was relied upon; and if your claim involves urgent care, your request for an appeal may be submitted orally or in writing, and all necessary information, including the appeal decision, is to be transmitted between the Plan and you by telephone, facsimile, or other similarly expeditious method. The Administrative Committee of the Board of Trustees reviews appeals of denied claims and makes final determinations. The Administrative Committee has full discretionary authority, including power to administer, construe and interpret the terms and provisions of the Plan, SPD and Trust Agreement and to determine eligibility for benefits under the Plan. 15.16.1.6 Timing of Appeal Decision – Precertification Medical Benefit Claims 15.16.1.6.1 Urgent care precertification claims A decision on your appeal will be made as soon as possible, but no later than 72 hours after an appeal is received. 15.16.1.6.2 Regular precertification claims A decision on your appeal will be made within a reasonable period of time, but no later than 30 days after an appeal is received. 15.16.1.7 Timing of Appeal Decision – Medical Benefit Claims After Service or Treatment Your appeal generally will be addressed at the next regularly scheduled quarterly meeting of the Administrative Committee after an appeal is received. If, however, your appeal is received within 30 days prior to such a meeting, it will be considered by the second regularly scheduled quarterly meeting after it is received. In addition, if special circumstances require an extension of time for processing your appeal, a decision will be rendered no later than the third regularly scheduled quarterly meeting after your appeal is received. Written notice of any extension of time will be sent before it commences explaining the reason for the extension and the expected date of the appeal determination. Notice of the appeal decision will be provided not later than five days after the decision is made. If an extension is required because you have not provided the information necessary to decide your claim, the time period for processing your claim will not run from the date of notice of an extension until the earlier of 1) the date the Plan receives your response to a request for additional information or 2) the date set by the Plan for your requested response (at least 45 days from the date of the request). 15.16.1.8 Hearing on Appeal Within a reasonable time after receipt of the request for review, you will be notified of the date, time and place of the appeal hearing by regular mail addressed to your address as shown on the request for review. You may request to be present at the hearing before the Administrative Committee. You may be represented at the hearing by an attorney or any other representative of your choosing. The proceedings at the hearing may be recorded by a method determined by the Committee. In conducting the hearing, the Committee shall not be bound by the usual common law or statutory rules of evidence. Copies will be made of all statements, documents, and records that you or your authorized representative introduces at the hearing and all other Relevant Documents. This information will be attached to the record of the hearing, and made a part thereof. 15.16.1.9 Contents of Appeal Decision – Medical Benefit Claims If you appeal a denied claim, the decision on review will be in writing and will include the following information: the specific reason or reasons for the decision; reference to the specific Plan provisions on which the decision is based; a statement of your right to receive, upon request free of charge, reasonable access to and copies of all Relevant Documents; a statement of your right to bring a civil action under Section 502(a) of ERISA; a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in deciding your claim for benefits on review, or a statement that such was relied upon and that a copy will be provided free of charge upon request; if the decision on review was based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying plan terms to your medical circumstances, or a statement that an explanation will be provided free of charge upon request; and the following statement: “You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U. S. Department of Labor Office and your State insurance regulatory agency.” 15.16.1.10 Relevant Documents Relevant Document means any document, record or other information that: was relied upon in making a decision to deny benefits; was submitted, considered, or generated in the course of making the decision to deny benefits, whether or not it was relied upon in making the decision to deny benefits; demonstrates compliance with any administrative processes and safeguards designed to confirm that the benefit determination was in accord with the plan and that plan provisions, where appropriate, have been applied consistently regarding similarly situated individuals; or constitutes a statement of policy or guidance with respect to the plan concerning a denied treatment option or benefit for the claimant’s diagnosis, without regard to whether such advice or statement was relied upon in making the decision to deny benefits.