APPEAL TO PLAN ADMINISTRATOR. (a) An enrollee may appeal to the plan administrator from a final decision by the claims payer denying the enrollee’s claim in whole or in part. A “final decision by the claims payer” is a decision that is not subject to any further review by the claims payer.
(b) The enrollee’s appeal must be in writing, must explain the grounds for the appeal, and must be postmarked or received by the plan administrator within forty five (45) days of the date that the enrollee received written notice of the final decision by the claims payer. The enrollee may submit documentation in support of the appeal. The plan administrator may waive the filing requirement of this subsection if there are extraordinary medical circumstances resulting in the enrollee’s inability to meet the filing requirement. In addition, an appeal submitted within ninety (90) days of the signing of this agreement, regardless of the date an enrollee received notice of the final decision from the claims payer, shall be reviewed by the plan administrator.
(c) The plan administrator shall send a final written decision on the appeal within 30 days of the date that the appeal is received, unless the administrator determines that additional information is necessary for resolution of the appeal. If the administrator determines that additional information is necessary, the administrator shall allow the enrollee an additional thirty (30) days to submit the additional information. If the additional information is not furnished within thirty (30) days, the administrator may deny the appeal. If the additional information is furnished in a timely manner, the administrator shall send a final written decision on the appeal within thirty (30) days of the date that the additional information is received.
(d) Failure by the plan administrator to issue a written decision within the time frames established in this section result in the appeal proceeding to the next level of review as described in Section 4 below.
APPEAL TO PLAN ADMINISTRATOR. An enrollee may appeal to the plan administrator from a final decision by the claims payer denying the enrollee’s claim in whole or in part. A “final decision by the claims payer” is a decision that is not subject to any further review by the claims payer.
