2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 95
Procedures for all Claims
To receive benefits under the Dental/Vision Plan, the claimant (i.e. you and your covered Dependents) must follow
the procedures outlined in this section.
Post-Service Claims. For a post-service claim, the Dental/Vision Plan Administrator will notify you of the
Dental/Vision 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 Dental/Vision Plan Administrator needs additional time to
process a claim, the Dental/Vision Plan Administrator may extend the time for notifying you of the Dental/Vision
Plan's benefit determination on a one-time basis for up to 15 days provided that the Dental/Vision Plan Administrator
notifies you within 30 days after the Dental/Vision 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.
Manner and Content of Notice of Initial Adverse Determination
If the Dental/Vision Plan Administrator denies a claim, it must provide to you in writing or by electronic
communication:
An explanation of the specific reasons for the denial;
(1)
A reference to the Dental/Vision Plan provision or insurance contract provision upon which the Adverse
Determination is based;
(2)
A description of any additional information or material that you must provide in order to perfect the claim;
(3)
An explanation of why the additional material or information is necessary;
(4)
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;
(5)
A statement describing your right to request a second level appeal;
(6)
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
(7)
If the adverse determination is based on the Dental/Vision 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.
Internal Review of Initially Denied Claims and Appeal Procedures
If you submit a claim for Dental/Vision Plan benefits and it is initially denied under the procedures described above,
you may request a review of that Adverse Determination under the procedures described below. However, please
note that vision services under the Group Dental and Vision Plan, including the reimbursement of Vision Materials
are not appealable. Any vision services provided under the Medical Plan will be subject to claim procedures of that
Plan.
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.
91