Common use of Level Formal Appeal Clause in Contracts

Level Formal Appeal. The 1st Level Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Such 180 days will run concurrently with the 180 day time period applicable to an Informal Review as set forth herein. NOTE: 1st Level Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. The 1st Level Formal Appeal shall contain at least the following information: • the Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number; • the Insured’s SHL membership number and Group name; and • a brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The 1st Level Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department PO Box 14865 Las Vegas, NV 89114 Fax: 0-000-000-0000 Certificate of Coverage SHL will investigate the appeal. When the investigation is complete, the Insured will be informed in writing of the resolution within thirty (30) days of receipt of the request for the 1st Level Formal Appeal. This period may be extended one (1) time by SHL for up to fifteen (15) days, provided that the extension is necessary due to matters beyond the control of SHL and SHL notifies the Insured prior to the expiration of the initial thirty (30) day period of the circumstances requiring the extension and the date by which SHL expects to render a decision. If the extension is necessary due to a failure of the Insured to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information and the Insured shall be afforded at least forty-five (45) days from receipt of the notice to provide the information. If SHL is unable to resolve the Insureds appeal as additional information is required, SHL will contact the Insured to obtain their permission to withdraw the appeal. The Insured will receive written notification that the appeal that been withdrawn and advise of the ninety (90) day timeframe in which to reopen their appeal. If the 1st Level Formal Appeal results in an Adverse Benefit Determination, the Insured will be informed in writing of the following: • the specific reason or reasons for upholding the Adverse Benefit Determination; • reference to the specific Plan provisions on which the determination is based; • a statement that the Insured is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Insured’s Claim for Benefits; • a statement describing any voluntary appeal procedures offered by SHL and the Insured’s right to receive additional information describing such procedures; • for Insured’s whose coverage is subject to ERISA, a statement of the Insured’s right to bring a civil action under ERISA Section 502(a) following an Adverse Benefit Determination, if applicable; • a statement that any internal rule, guideline, protocol or other similar criteria that was relied on in making the determination is available free of charge upon the Insured’s request; and • if the Adverse Benefit Determination is based on Medical Necessity or Experimental, Investigational or Unproven treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment or a statement that such explanation will be provided free of charge as well as information regarding the Insured’s right to request an External Review by the State of Nevada’s Office for Consumer Health Assistance (OCHA). Limited extensions may be required if additional information is required in order for SHL to reach a resolution. If the resolution to the 1st Level Formal Appeal is not acceptable to the Insured and the Insured wishes to pursue the matter further, the Insured is entitled to file a 2nd Level Formal Appeal. The Insured will be informed of this right at the time the Insured is informed of the resolution of his 1st Level Formal Appeal.

Level Formal Appeal. When an Informal Review is not resolved in a manner that is satisfactory to the Member or when the Member chooses not to file an Informal Review and the Member wishes to pursue the matter further, the Member must file a 1st Level Formal Appeal. The 1st Level Formal Appeal must be submitted orally or in writing to SHLHPN’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Such 180 days will run concurrently with the 180 day time period applicable to an Informal Review as set forth herein. NOTE: 1st Level Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. The 1st Level Formal Appeal shall contain at least the following information: • the InsuredThe Member’s name (or name of Insured Member and InsuredMember’s Authorized Representative), address, and telephone number; • the InsuredThe Member’s SHL HPN membership number and Group name; and • a A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured Member feels that the Adverse Benefit Determination was wrong. Additionally, the Insured Member may submit any supporting medical records, Physician’s letters, or other information that explains why SHL HPN should approve the Claim for Benefits. The Insured Member can request the assistance of a Member Services Representative at any time during this process. The 1st Level Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co.Plan of Nevada, Inc. Attn: Customer Response and Resolution Department PO Box 14865 Las VegasXX Xxx 00000 Xxx Xxxxx, NV 89114 Fax: 0-000-000-0000 Certificate of Coverage SHL XX 00000 HPN will investigate the appeal. When the investigation is complete, the Insured Member will be informed in writing of the resolution within thirty (30) days of receipt of the request for the 1st Level Formal Appeal. This period may be extended one (1) time by SHL HPN for up to fifteen (15) days, provided that the extension is necessary due • to matters beyond the control of SHL HPN and SHL • HPN notifies the Insured Member prior to the expiration of the initial thirty (30) day period of the circumstances requiring the extension and the date by which SHL HPN expects to render a decision. If the extension is necessary due to a failure of the Insured Member to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information and the Insured Member shall be afforded at least forty-five (45) days from receipt of the notice to provide the information. If SHL HPN is unable to resolve the Insureds Members appeal as additional information is required, SHL HPN will contact the Insured Member to obtain their permission to withdraw the appeal. The Insured Member will receive written notification that the appeal that has been withdrawn and advise of the ninety (90) day timeframe in which to reopen their appeal. If the 1st Level Formal Appeal results in an Adverse Benefit Determination, the Insured Member will be informed in writing of the following: • the The specific reason or reasons for upholding the Adverse Benefit Determination; • reference Reference to the specific Plan provisions on which the determination is based; • a A statement that the Insured Member is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the InsuredMember’s Claim for Benefits; • a A statement describing any voluntary appeal procedures offered by SHL HPN and the InsuredMember’s right to receive additional information describing such procedures; • for InsuredFor Member’s whose coverage is subject to ERISA, a statement of the InsuredMember’s right to bring a civil action under ERISA Section 502(a) following an Adverse Benefit Determination, if applicable; • a A statement that any internal rule, guideline, protocol or other similar criteria that was relied on in making the determination is available free of charge upon the InsuredMember’s request; and • if the Adverse Benefit Determination is based on Medical Necessity or Experimental, Investigational or Unproven treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment or a statement that such explanation will be provided free of charge as well as information regarding the Insured’s right to request an External Review by the State of Nevada’s Office for Consumer Health Assistance (OCHA). Limited extensions may be required if additional information is required in order for SHL to reach a resolution. If the resolution to the 1st Level Formal Appeal is not acceptable to the Insured and the Insured wishes to pursue the matter further, the Insured is entitled to file a 2nd Level Formal Appeal. The Insured will be informed of this right at the time the Insured is informed of the resolution of his 1st Level Formal Appeal.and

Level Formal Appeal. The 1st Level Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Such 180 days will run concurrently with the 180 day time period applicable to an Informal Review as set forth hereinin Section 15.1. NOTE: 1st Level Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. The 1st Level Formal Appeal shall contain at least the following information: • the  The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number; • the  The Insured’s SHL membership number and Group name; and • a  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The 1st Level Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department PO Box 14865 Las Vegas, NV 89114 Fax: 0-000-000-0000 Certificate of Coverage SHL will investigate the appeal. When the investigation is complete, the Insured will be informed in writing of the resolution within thirty (30) days of receipt of the request for the 1st Level Formal Appeal. This period may be extended one (1) time by SHL for up to fifteen (15) days, provided that the extension is necessary due to matters beyond the control of SHL and SHL notifies the Insured prior to the expiration of the initial thirty (30) day period of the circumstances requiring the extension and the date by which SHL expects to render a decision. If the extension is necessary due to a failure of the Insured to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information and the Insured shall be afforded at least forty-five (45) days from receipt of the notice to provide the information. If SHL is unable to resolve the Insureds appeal as additional information is required, SHL will contact the Insured to obtain their permission to withdraw the appeal. The Insured will receive written notification that the appeal that has been withdrawn and advise of the ninety (90) day timeframe in which to reopen their appeal. If the 1st Level Formal Appeal results in an Adverse Benefit Determination, the Insured will be informed in writing of the following: • the  The specific reason or reasons for upholding the Adverse Benefit Determination; • reference  Reference to the specific Plan provisions on which the determination is based; • a  A statement that the Insured is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Insured’s Claim for Benefits; • a  A statement describing any voluntary appeal procedures offered by SHL and the Insured’s right to receive additional information describing such procedures; • for Insured’s whose coverage is subject to ERISA, a statement of the Insured’s right to bring a civil action under ERISA Section 502(a) following an Adverse Benefit Determination, if applicable; • a statement that any internal rule, guideline, protocol or other similar criteria that was relied on in making the determination is available free of charge upon the Insured’s request; and • if the Adverse Benefit Determination is based on Medical Necessity or Experimental, Investigational or Unproven treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment or a statement that such explanation will be provided free of charge as well as information regarding the Insured’s right to request an External Review by the State of Nevada’s Office for Consumer Health Assistance (OCHA). Limited extensions may be required if additional information is required in order for SHL to reach a resolution. If the resolution to the 1st Level Formal Appeal is not acceptable to the Insured and the Insured wishes to pursue the matter further, the Insured is entitled to file a 2nd Level Formal Appeal. The Insured will be informed of this right at the time the Insured is informed of the resolution of his 1st Level Formal Appeal.;

Level Formal Appeal. The 1st Level Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Such 180 days will run concurrently with the 180 day time period applicable to an Informal Review as set forth herein. NOTE: 1st Level Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. The 1st Level Formal Appeal shall contain at least the following information: • the  The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number; • the  The Insured’s SHL membership number and Group name; and • a  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The 1st Level Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department PO Box 14865 Las Vegas, NV 89114 Fax: 0-000-000-0000 Certificate of Coverage SHL will investigate the appeal. When the investigation is complete, the Insured will be informed in writing of the resolution within thirty (30) days of receipt of the request for the 1st Level Formal Appeal. This period may be extended one (1) time by SHL for up to fifteen (15) days, provided that the extension is necessary due to matters beyond the control of SHL and SHL notifies the Insured prior to the expiration of the initial thirty (30) day period of the circumstances requiring the extension and the date by which SHL expects to render a decision. If the extension is necessary due to a failure of the Insured to submit the information necessary to decide the claim, Certificate of Coverage the notice of extension shall specifically describe the required information and the Insured shall be afforded at least forty-five (45) days from receipt of the notice to provide the information. If SHL is unable to resolve the Insureds appeal as additional information is required, SHL will contact the Insured to obtain their permission to withdraw the appeal. The Insured will receive written notification that the appeal that been withdrawn and advise of the ninety (90) day timeframe in which to reopen their appeal. If the 1st Level Formal Appeal results in an Adverse Benefit Determination, the Insured will be informed in writing of the following: • the  The specific reason or reasons for upholding the Adverse Benefit Determination; • reference  Reference to the specific Plan provisions on which the determination is based; • a  A statement that the Insured is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Insured’s Claim for Benefits; • a  A statement describing any voluntary appeal procedures offered by SHL and the Insured’s right to receive additional information describing such procedures; • for  For Insured’s whose coverage is subject to ERISA, a statement of the Insured’s right to bring a civil action under ERISA Section 502(a) following an Adverse Benefit Determination, if applicable; • a  A statement that any internal rule, guideline, protocol or other similar criteria that was relied on in making the determination is available free of charge upon the Insured’s request; and • if  If the Adverse Benefit Determination is based on Medical Necessity or Experimentalexperimental, Investigational investigational or Unproven unproven treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment or a statement that such explanation will be provided free of charge as well as information regarding the Insured’s right to request an External Review by the State of Nevada’s Office for Consumer Health Assistance (OCHA). Limited extensions may be required if additional information is required in order for SHL to reach a resolution. If the resolution to the 1st Level Formal Appeal is not acceptable to the Insured and the Insured wishes to pursue the matter further, the Insured is entitled to file a 2nd Level Formal Appeal. The Insured will be informed of this right at the time the Insured is informed of the resolution of his 1st Level Formal Appeal.