2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 73
(4)
Post-Service Claims. For a post-service claim, the Plan Administrator will notify you of the Plan's Adverse
Determination within a reasonable period of time, but not later than 30 days after receipt of the claim. If, due
to special circumstances, the Plan Administrator needs additional time to process a claim, the Plan
Administrator may extend the time for notifying you of the Plan's benefit determination on a one-time basis for
up to 15 days provided that the Plan Administrator notifies you within 30 days after the Plan receives the claim,
of those special circumstances and of the date by which the reviewer expects to make a decision. However,
if such a decision is necessary due to your failure to submit the information necessary to decide the claim, the
notice of extension will specifically describe the required information and you will be afforded at least 45 days
from receipt of the notice within which to provide the specified information.
A claim for benefits is considered a post-service claim if it is a request for payment for services or other benefits
that you have already received (or any other claim for health benefits that is not a pre-service claim or an
urgent care claim).
(5)
No Surprises Act Claims. If you think you have been wrongly billed or are in receipt of a Surprise Bill by a
Non-Participating Provider for Medical Emergency services or services provided at a Network facility, contact
the Plan Administrator.
Manner and Content of Notice of Initial Adverse Determination
If the Plan Administrator denies a claim, it must provide to you in writing or by electronic communication:
(1)
An explanation of the specific reasons for the Adverse Determination;
(2)
A reference to the Plan provision or insurance contract provision upon which the Adverse Determination is
based;
(3)
A description of any additional information or material that you must provide in order to perfect the claim;
(4)
An explanation of why the additional material or information is necessary;
(5)
Notice that you have the right to request a review of the Adverse Determination and information on the steps
to be taken if you wish to request a review of the Adverse Determination along with the time limits applicable
to a request for review;
(6)
A statement describing your right to request a second level appeal, or if applicable, to bring an action for
judicial review;
(7)
A copy of any rule, guideline, protocol or other similar criterion relied upon in making the Adverse
Determination (or a statement that the same will be provided upon your request and without charge); and
(8)
If the Adverse Determination is based on the Plan's Medical Necessity, Experimental treatment or similar
exclusion or limit, either: (a) an explanation of the scientific or clinical judgment applying the exclusion or limit
to your medical circumstances or (b) a statement that the same will be provided upon your request and without
charge.
For an Adverse Determination concerning an urgent care claim, the information described in this Section may be
provided to you orally within the permitted time frame provided that a written or electronic notification in accordance
with this section is furnished to you no later than 3 days after the oral notification.
Internal Review of Initial Adverse Benefit Determination and Appeal Procedures
If you submit a claim for Plan benefits and it is initially denied under the procedures described above, you may request
a review of that Adverse Determination under the appeal procedures described below.
You have 180 days after you receive notice of an initial Adverse Determination within which to request a review of the
Adverse Determination. For a request for a second level appeal, you have 60 days after you receive notice of an
Adverse Determination at the first level of appeal to request a second level appeal of the Adverse Determination.
If you request a review of an Adverse Determination within the applicable time period, the review will meet the following
requirements:
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