Notification of an Adverse Benefit Determination. If you receive an Adverse Benefit Determination, you 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 description of any additional material or information necessary for the Claim for Benefits to be approved, modified or reversed, and an explanation of why such material or information is necessary; A description of the review procedures and the time limits applicable to 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 appeal of 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 unproventreatment 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.
Notification of an Adverse Benefit Determination. If you receive an Adverse Benefit Determination, you 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 description of any additional material or information necessary for the Claim for Benefits to be approved, modified or reversed, and an explanation of why such material or information is necessary; A description of the review procedures and the time limits applicable to such procedures;
Notification of an Adverse Benefit Determination. The Administration Office shall provide a participant with a notice, either in writing or electronically containing the following information:
Notification of an Adverse Benefit Determination. SHL shall notify the Insured within twenty-four (24) hours after receipt of the Claim for Benefits by the Plan, provided that the request is received at least twenty-four (24) hours prior to the expiration of the authorized period of time or number of treatments. If the request is not made at least twenty-four (24) hours prior to the expiration of the authorized period of time or number of treatments, the request will be treated as an Urgent Care Claim. If an Insured fails to follow the Plan’s procedures for filing a request for Prior Authorization (Pre-Service Claim), the Insured shall be notified of the failure and the proper procedures to be followed in order to obtain Prior Authorization provided the Insured’s request for Prior Authorization is received by an employee or department of the Plan customarily responsible for handling benefit matters and the original request specifically named the Insured, a specific medical condition or symptom, and a specific treatment, service or product for which approval is requested. The Insured notification of correct Prior Authorization procedures from the Plan shall be provided as soon as possible, but not later than five (5) days (twenty-four (24) hours in the case of an Urgent Care Claim) following the Plan’s receipt of the Insured’s original request. Notification by SHL may be oral unless specifically requested in writing by the Insured.
Notification of an Adverse Benefit Determination. Any request by a Member to extend the course of treatment beyond the period of time or number of treatments for an Urgent Care Claim shall be decided as soon as possible. HPN shall notify the Member within twenty-four (24) hours after receipt of the Claim for Benefits by the Plan, provided that the request is received at least twenty-four (24) hours prior to the expiration of the authorized period of time or number of treatments. If the request is not made at least twenty-four (24) hours prior to the expiration of the authorized period of time or number of treatments, the request will be treated as an Urgent Care Claim. If you receive an Adverse Benefit Determination, you 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 description of any additional material or information necessary for the Claim for Benefits to be approved, modified or reversed, and an explanation of why such material or information is necessary; • A description of the review procedures and the time limits applicable to such procedures; • For Member’s whose coverage is subject to ERISA, a statement of the Member’s right to bring a civil action under ERISA Section 502(a) following an appeal of 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 Member’s request; and • If the Adverse Benefit Determination is based on Medical Necessity or experimental 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.
Notification of an Adverse Benefit Determination. If you receive an Adverse Benefit Determination, you 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 description of any additional material or information necessary for the Claim for Benefits to be approved, modified or reversed, and an explanation of why such material or information is necessary; • A description of the review procedures and the time limits applicable to such procedures; • 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 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.
Notification of an Adverse Benefit Determination. If you receive an Adverse Benefit Determination, you 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 description of any additional material or information necessary for the Claim for Benefits to be approved, modified or reversed, and an explanation of why such material or information is necessary; • A description of the review procedures and the time limits applicable to such procedures; • For Member’s whose coverage is subject to ERISA, a statement of the Member’s right to bring a civil action under ERISA Section 502(a) following an appeal of 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 Member’s request; and • If the Adverse Benefit Determination is based on Medical Necessity or experimental 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.
