2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 97
(3)
The relevant Dental/Vision 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 Dental/Vision 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 Dental/Vision 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 Dental/Vision 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 a denied
claim) is filed in accordance with the Dental/Vision 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 Dental/Vision 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 Dental/Vision 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.
Dental/Vision Plan's Failure to Follow Procedures
If the Dental/Vision Plan fails to follow the claim procedures described above, you will be deemed to have exhausted
the Dental/Vision Plan internal claim procedures and you will be entitled to pursue any available remedy under
State or Federal law on the basis that the Dental/Vision 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 Dental/Vision Plan's claims procedures will be construed to supersede any provision of any applicable
State law.
Statute of Limitations for Dental/Vision Plan Claims and Appeals
Please note that no legal action may be commenced or maintained to recover benefits under the Dental/Vision Plan
more than 12 months after the final review/appeal decision by the Plan Administrator has been rendered (or deemed
rendered).
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