B. CLAIMS AND APPEALS PROCEDURES B DEFINITIONS

1. Adverse Benefit Determination.

An “Adverse Benefit Determination” is any denial, reduction, termination of or failure to provide or make payment for a benefit (either in whole or in part) under the Plan. Each of the following is an example of an Adverse Benefit Determination:

1. a payment of less than 100% of a Claim for benefits (including coinsurance or co-payment amounts of less than 100% and amounts applied to the deductible);


2. a denial, reduction, termination of or failure to provide or make payment for a benefit (in whole or in part) resulting from any utilization review decision;


3. a failure to cover an item or service because the Plan considers it to be Experimental, Investigational, not Medically Necessary;


4. a restriction on reimbursement for particular services because they are classified as related to a mental or nervous, rather than a physical, condition; and


5. a decision that denies a benefit based on a determination that a claimant is not eligible to participate in the Plan.

Presentation of a prescription order at a pharmacy, where the pharmacy refuses to fill the prescription unless the Participant pays the entire cost, is not considered an Adverse Benefit Determination (but only to the extent that the pharmacy’s decision for denying the prescription is based on coverage rules predetermined by the Plan).

2. Claim.

The term “Claim” means a request for a benefit made by a Participant in accordance with the Plan’s reasonable procedures.

Casual inquiries about benefits or the circumstances under which benefits might be paid are not considered Claims. Nor is a request for a determination of whether an individual is eligible for benefits under the Plan considered to be a Claim. However, if a Participant files a Claim for specific benefits, and the Claim is denied because the individual is not eligible under the terms of the Plan, that coverage determination is considered a Claim.

The presentation of a prescription order at a pharmacy does not constitute a Claim, to the extent benefits are determined based on cost and coverage rules predetermined by the Plan. If a Physician, Hospital or pharmacy declines to render services or refuses to fill a prescription unless the Participant pays the entire cost, the Participant should submit a Post-Service Claim for the services or prescription, as described under these procedures, below.

A request for pre-certification or prior authorization of a benefit that does not require pre-certification or prior authorization by the Plan is not considered a Claim. However, requests for pre-certification or prior authorization of a benefit where the Plan does require pre-certification or prior authorization are considered Claims and should be submitted as Pre-Service Claims (or Urgent Claims, if applicable), as described under Claim Procedures, below.

Claims are Categorized as Follows:

1. Urgent Claim. The term “Urgent Claim” means a Claim for medical care or treatment that:
   1. if normal Pre-Service Claim standards for rendering a decision were applied, would seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function; or
   2. in the opinion of a Physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that could not be adequately managed without the care or treatment that is the subject of the Claim.


2. Pre-Service Claim. The term “Pre-Service Claim” means a Claim for a benefit for which the Plan requires pre-certification or prior authorization before medical care is obtained in order to receive the maximum benefits allowed under the Plan.


3. Concurrent Claim. The term “Concurrent Claim” means a Claim that is reconsidered after an initial approval has been made which results in a reduction, termination or extension of the previously approved benefit.


4. Post-Service Claim. The term “Post-Service Claim” means a Claim for benefits that is not a Pre-Service, Urgent or Concurrent Claim. This will generally be a claim for reimbursement for services already rendered.


5. Disability Claim. The term “Disability Claim” means any Claim that requires a finding of total disability as a condition of eligibility.

3. Relevant Documents.

“Relevant Documents” include documents pertaining to a Claim if they were relied upon in making the benefit determination, were submitted, considered or generated in the course of making the benefit determination, demonstrate compliance with the administrative processes and safeguards required by the regulations, or constitute the Plan’s policy or guidance with respect to the denied treatment option or benefit. Relevant Documents could include specific Plan rules, protocols, criteria, rate tables, fee schedules or checklists and administrative procedures that prove that the Plan’s rules were appropriately applied to a Claim.