2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 75
Manner and Content of Notice of Decision on Internal Review of Initial Adverse Benefit Determinations
Upon completion of its review of an initial Adverse Determination (or a first-level appeal Adverse Determination), the
reviewer will give you, in writing or by electronic notification, a notice of its benefit determination. For an Adverse
Determination, the notice will include:
(1)
A description of the Plan’s decision;
(2)
The specific reasons for the decision;
(3)
The relevant Plan provisions or insurance contract provisions on which its decision is based;
(4)
A statement that you are entitled to receive, upon request and without charge, reasonable access to and
copies of, all documents, records and other information in the Plan's files which is relevant to your claim for
benefits;
(5)
A statement describing your right to request a second level appeal or, if applicable, to bring an action for
judicial review;
(6)
If an internal rule, guideline, protocol or other similar criterion was relied upon in making the Adverse
Determination on review, a statement that a copy of the rule, guideline, protocol or other similar criterion will
be provided without charge to you upon request;
(7)
If the Adverse Determination on review is based on a Medical Necessity, Experimental treatment or similar
exclusion or limit, either: (a) an explanation of the scientific or clinical judgment on which the determination
was based, applying the terms of the Plan to the claimant's medical circumstances or (b) a statement that
such an explanation will be provided without charge upon request.
Calculation of Time Periods for Appeals
For purposes of the time periods described in the Plan's claim procedures, the period of time during which a benefit
determination is required to be made begins at the time a claim (or a request for review of an adverse benefit
determination) is filed in accordance with the Plan procedures without regard to whether all the information necessary
to make a decision accompanies the request. If a period of time is extended due to your failure to submit all information
necessary for a claim for non-urgent care benefits, the period for making the determination is "frozen" from the date
the notification requesting the additional information is sent to you until the date you respond or, if earlier, until 45
days from the date you receive (or were reasonably expected to receive) the notice requesting additional information.
Adverse Determination
For purposes of the Plan's claim procedures, an " Adverse Determination " is a denial, reduction or termination of or
a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination
or failure to provide or make payment that is based on a determination of an individual's eligibility to participate in the
Plan and including a denial, reduction or termination of or a failure to provide or make payment (in whole or in part)
for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for
which benefits are otherwise provided because it is determined to be Experimental and/or Investigational or not
Medically Necessary or appropriate. Adverse Determination also includes any rescission of coverage, whether or not,
in connection with the rescission, there is an adverse effect on any particular benefit at the time of rescission.
Plan's Failure to Follow Procedures
If the Plan fails to follow the claim procedures described above, you will be deemed to have exhausted the Plan
internal claim procedures and you will be entitled to pursue any available remedy under state or federal law on the
basis that the Plan has failed to provide a reasonable claims procedure that would yield a decision on the merits of
the claim.
State Insurance Laws
Nothing in the Plan's claims procedures will be construed to supersede any provision of any applicable state law.
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