Receiving Your Benefits

If Your Claim Is Denied

Review of Appeal

An independent fiduciary (or in the case of UCHP, a committee of UCPG physicians) will review and give a decision on your appeal within the time frames outlined below and will notify you of its decision in writing. The independent fiduciary will not be an individual who participated in or decided your original claim nor be a subordinate to the original decision maker. No deference will be given to the initial decision. The independent fiduciary may consult with a physician or other licensed health care professional to receive advice or other such evidence as it deems necessary to decide your claim, except that any medical or dental expert consulted in connection with your appeal will be different from any expert consulted in your initial claim. (The identity of a medical or dental expert consulted in connection with your appeal will be provided.)

The time frame review of your appeal, like your initial claim for benefits, depends on whether it is an urgent care claim, a claim requiring advance approval or pre-authorization, approval of an ongoing course of treatment or post-service claim. Please pay attention to the following time frames:

Urgent Care Claims

If your appeal is in connection with an urgent care claim, the Plan Administrator will notify you of its decision on appeal as soon as possible taking into account medical or dental circumstances, but not later than 72 hours after the plan received the appeal.

Claim Requiring Advance Approval or Pre-Authorization

If your appeal is in connection with a claim for benefits requiring advance approval by the Plan Administrator, you will be notified of its decision on appeal, adverse or not, within a reasonable period of time appropriate to the medical or dental circumstances, but not later than 30 days after the plan received your appeal.

Approval of an Ongoing Course of Treatment

If your appeal is in connection with a claim for an ongoing course of treatment, the Plan Administrator will notify you of its decision on appeal as soon as possible, but not later than the date your treatment ends or is reduced.

Post-Service Claim

If your appeal is in connection with a claim for payment of services after they have been received, the Plan Administrator will notify you of its decision on appeal, adverse or not, but not later than 60 days after the plan received appeal.

While this Summary Plan Description summarizes the major provisions of this plan, it does not provide you with every plan detail. The plan documents, which govern this plan, provide full details. If there are any discrepancies between this Summary Plan Description and the legal plan documents, the legal plan documents control.