- CLAIM AND APPEAL PROCEDURES Sample Clauses

- CLAIM AND APPEAL PROCEDURES. A Claimant must submit any required forms and pertinent information when making a claim for benefits under the Plan. If a claim for benefits under the Plan is denied, the Plan Administrator shall provide adequate written notice to any Claimant whose claim for benefits under the Plan has been denied. The notice must be furnished within 90 days of the date that the claim is received by the Plan Administrator. The Claimant shall be notified in writing within this initial 90-day period if special circumstances require an extension of time needed to process the claim and the date by which the Plan Administrator's decision is expected to be tendered. The written notice shall be furnished no later than 180 days after the date the claim was received by the Plan Administrator. The Plan Administrator's notice to the Claimant shall specify the reason for the denial; specify references to pertinent Plan provisions on which denial is based; describe any additional material and information needed for the Claimant to perfect his claim for benefits; explain why the material and information is needed; inform the Claimant that any appeal he wishes to make must be made in writing to the Plan Administrator within 60 days after receipt of the Plan Administrator's notice of denial of benefits and that failure to make the written appeal within such 60-day period renders the Plan Administrator's determination of such denial final, binding and conclusive. If the Claimant appeals to the Plan Administrator, the Claimant, or his authorized representative, may submit in writing whatever issues and comments the Claimant, or the representative, feels are pertinent. The Claimant, or the authorized representative, may review pertinent Plan documents. The Plan Administrator shall reexamine all facts related to the appeal and make a final determination as to whether the denial of benefits is justified under the circumstances. The Plan Administrator shall advise the Claimant of its decision within 60 days of his written request for review, unless special circumstances (such as a hearing) would make rendering a decision within the 60-day limit unfeasible. The Claimant shall be notified within the 60-day limit if an extension is necessary. The Plan Administrator shall render a decision on a claim for benefits no later than 120 days after the request for review is received.

- CLAIM AND APPEAL PROCEDURES. A. TIME LIMIT FOR FILING A POSTSERVICE CLAIM: In order to receive benefits under the Contract, We must be notified when the Covered Person has received Services. A Claim should be filed by a Provider or Covered Person within 90 days after the date of Service. Contracting Providers will file Claims on the Covered Person’s behalf. Claims that are not filed by a Nebraska Contracting Provider within 90 days after the date of Service, will become the Nebraska Contracting Provider's liability. If a Claim is submitted by a non-Contracting Provider more than 90 days after the date of Service, benefits will not be paid. If the Claim is not submitted by Covered Person within 15 months of the date of Service, except in the absence of legal capacity, benefits will not be paid. All Claims for Services by non-Contracting Providers that are submitted beyond the claim filing time are the Covered Person’s responsibility. B. CLAIM FORMS: Upon notice of a Claim, We will provide a Claim form within 15 days, if requested. If the form is not supplied within 15 days, the Provider or Covered Person will be deemed to have complied with the requirements of this Contract as to proof of loss upon submitting, within the time frame indicated above, written proof indicating the Service provided, the nature of that Service and the expense incurred. CLAIMS SHOULD BE SENT TO: Blue Cross and Blue Shield of Nebraska P.O. Box 3248 Omaha, Nebraska 68180-0001

- CLAIM AND APPEAL PROCEDURES