Common use of Appeals of Adverse Benefit Determinations Clause in Contracts

Appeals of Adverse Benefit Determinations. The covered person may submit an appeal if Aetna gives notice of an adverse benefit determination. This Plan provides for one level or two levels (Level Two only applies to dental, vision and hearing claims) of appeal. A final adverse benefit determination notice may also provide an option to request an External Review (if available). An appeal of an adverse benefit determination will be evaluated and reviewed by a clinical peer, not involved in the original determination. A clinical peer is: • A physician or other health care professional who holds a non-restricted license in a state of the US and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review. • For urgent care reviews concerning child or adolescent substance use disorder or mental disorder, holds a national board certification in child and adolescent psychiatry or a doctoral level psychology degree with training and clinical experience in the treatment of child and adolescent substance use and mental disorder as applicable. • For urgent care reviews concerning adult substance use or mental disorder, holds a national board certification in psychiatry, or a doctoral level psychology degree with training and clinical experience in the treatment of adult substance use and mental disorders, as applicable. The covered person has 180 calendar days with respect to Health Claims following the receipt of notice of an adverse benefit determination to request their Level One appeal. The covered person’s appeal must be submitted in writing and must include: • The covered person’s name. • The Policyholder's name. • A copy of Aetna’s notice of an adverse benefit determination. • The covered person’s reasons for making the appeal. • Any other information the covered person would like to have considered. The covered person can send their written appeal to Member Services at the address shown on their ID Card. The covered person may also choose to have another person (an authorized representative) make the appeal on their behalf. The covered person must provide written consent to Aetna. The covered person may be allowed to provide evidence or testimony during the appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services.

Appeals of Adverse Benefit Determinations. The When the covered person may submit an appeal if Aetna gives notice of receives an adverse benefit determinationdetermination that was based on medical necessity, Aetna must notify the covered person’s physician or other health care professional of the opportunity to confer, at the physician or other health care professional’s request, with a clinical peer of Aetna. This conference will not be considered a grievance of the adverse benefit determination as long the covered person or the covered person’s authorized representative has not submitted an appeal to Aetna. This Plan provides for one level or two levels (Level Two only applies to dental, vision and hearing claims) of appeal. A final adverse benefit determination notice may also provide an option to request an External Review (if available). An appeal of an adverse benefit determination will be evaluated and reviewed by a clinical peer, not involved in the original determination. A clinical peer is: • A physician or other health care professional who holds a non-restricted license in a state of the US and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review. • For urgent care reviews concerning child or adolescent substance use disorder or mental disorder, holds a national board certification in child and adolescent psychiatry or a doctoral level psychology degree with training and clinical experience in the treatment of child and adolescent substance use and mental disorder as applicable. • For urgent care reviews concerning adult substance use or mental disorder, holds a national board certification in psychiatry, or a doctoral level psychology degree with training and clinical experience in the treatment of adult substance use and mental disorders, as applicable. The covered person has 180 calendar days with respect to Health Claims following the receipt of notice of an adverse benefit determination to request their Level One appeal. The covered person’s appeal may be submitted orally or must be submitted in writing and must include: • The covered person’s name. • The Policyholder's name. • A copy of Aetna’s notice of an adverse benefit determination. • The covered person’s reasons for making the appeal. • Any other information the covered person would like to have considered. The covered person can send their written appeal to Member Services at the address shown on their ID Card, or call in their appeal to Member Services using the telephone number shown on their ID Card. The covered person may send their written appeal to the address shown on the notice of adverse benefit determination, or they may call in their appeal using the telephone number listed on the notice. The covered person may also choose to have another person (an authorized representative) make the appeal on their behalf. The covered person must provide written consent to Aetna. The covered person may be allowed to provide evidence or testimony during the appeal process in accordance with the guidelines established by the Federal Department of Health and Human Services. This amendment makes no other changes to the Policy. Xxx Xxxxx President Aetna Life Insurance Company (A Stock Company) Amendment: 5 Issue Date: July 2, 2021 Hartford, Connecticut 06156 The date a person becomes a covered person under the Student Accident Policy. The Student Accident policy noted above has been changed. The following is a summary of the changes in the Policy. This amendment is effective on the date(s) shown above.