Common use of Appeals Denial Notices Clause in Contracts

Appeals Denial Notices. Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX or by e- mail, as appropriate, within the time periods noted above. A notice that a claim appeal has been denied will include: • The specific reason or reasons for the adverse determination. • Reference to the specific plan provision upon which the determination is based. • If any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of the rule, protocol or similar criterion will be provided to the Claimant, free of charge, upon request. • A statement describing any voluntary appeal procedures offered by the plan and the claimant's right to obtain the information about such procedures, and a statement about the Claimant's right to bring an action under section 502(a) of ERISA. • If an adverse determination is based on medical necessity, experimental treatment or similar exclusion or limitation, the notice will state that an explanation of the scientific or clinical basis for the determination will be provided, free of charge, upon request. The explanation will apply the terms of the plan to the covered person's medical circumstances. In the event an appealed claim is denied, the Claimant, will be entitled to receive without charge reasonable access to, and copies of, any documents, records or other information that: • Was relied upon in making the determination. • Was submitted, considered or generated in the course of making the benefit determination, without regard to whether such document, record or other information was relied upon in making the benefit determination. • Demonstrates compliance with the administrative processes and safeguards required in making the determination. • Constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant's diagnosis, without regard to whether the statement was relied on in making the benefit determination.

Appeals Denial Notices. Notice of a claim denial (including a partial denial) will be provided to Claimants by mail, postage prepaid, by FAX or by e- mailemail, as appropriate, within the time periods noted above. A notice that a claim appeal has been denied will include: • The specific reason or reasons for the adverse determination. • Reference to the specific plan provision upon which the determination is based. • If any internal plan rule, protocol or similar criterion was relied upon to deny the claim. A copy of the rule, protocol or similar criterion will be provided to the Claimant, free of charge, upon request. • A statement describing any voluntary appeal procedures offered by the plan and the claimant's ’s right to obtain the information about such procedures, and a statement about the Claimant's ’s right to bring an action under section 502(a) of ERISA. • If an adverse determination is based on medical necessity, experimental treatment or similar exclusion or limitation, the notice will state that an explanation of the scientific or clinical basis for the determination will be provided, free of charge, upon request. The explanation will apply the terms of the plan to the covered person's ’s medical circumstances. In the event an appealed claim is denied, the Claimant, will be entitled to receive without charge reasonable access to, and copies of, any documents, records or other information that: • Was relied upon in making the determination. • Was submitted, considered or generated in the course of making the benefit determination, without regard to whether such document, record or other information was relied upon in making the benefit determination. • Demonstrates compliance with the administrative processes and safeguards required in making the determination. • Constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant's ’s diagnosis, without regard to whether the statement was relied on in making the benefit determination.