APPEALS

How to Appeal an Adverse Benefit Determination 

If your Claim is denied in whole or in part, (an Adverse Benefit Determination) or if you disagree with the decision made on your Claim, you or your Authorized Representative may request a review by the Board through the Internal Appeals process. Your request for review must:

Be made in writing;

• State the reason(s) for disputing the denial (the Adverse Benefit Determination);
• Include any pertinent materials not already furnished to the Plan; and

Be submitted within 180 days from the date you receive the Adverse Benefit Determination.

The Internal Appeals Procedures

You have the right to review documents relative to your Claim. A document, record or other information is “relevant” if it was relied upon by the Plan in making the decision on your Claim; it was submitted, considered, or generated (regardless of whether it was relied upon); it demonstrates compliance with the Plan’s administrative processes for providing consistent decision making; or it constitutes a statement of Plan policy regarding the denied treatment of service.

Upon request, you will be provided with the identification of the appropriate medical expert, consultant, or advisor, if any, that gave advice to the Plan on your Claim, without regard to whether the advice of those experts was relied upon in deciding your Claim.

A different person will review your Claim from the one who made the original decision. The reviewer will not give deference to the initial Adverse Benefit Determination. The decision will be made on the basis of the record, including any additional documents and comments that may be submitted by you.

If your claim was denied on the basis of a medical judgement (such as a determination that the treatment of service was not Medically Necessary, or was investigative or experimental), a health care professional with the appropriate training and experience in a relevant field or medicine will be consulted. 

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