Common use of Review and Interpretation of the Plan Clause in Contracts

Review and Interpretation of the Plan. HEBP will receive and review claims for benefits under the Plan. The operation and administration of the Plan require uniformity regarding the intent and the interpretation of the Plan’s provisions. The Plan Administrator has full and complete authority and discretion to make decisions regarding Plan provisions and to determine questions of eligibility and benefits. HEBP assumes only the authority and discretion as given by the Plan Administrator to interpret benefits based on medical necessity, allowable amount, or experimental/investigational guidelines that are in accordance with the provisions in Member’s Plan. Any decision that is not arbitrary or capricious shall be final and conclusive, subject to any right to appeal a determination to the Plan Administrator. On occasion, HEBP, in its role as Claims Administrator, may deny all or part of submitted claims. HEBP will provide a full and fair review of any determination of a claim, any determination of a request for precertification, and any other determination made as the Claims Administrator in accordance with the benefits and procedures detailed in Member’s Plan. HEBP will use its best efforts, consistent with administrative practices and any procedures established in writing between HEBP and the Plan and consistent with industry standards, to accurately process all claims.

Review and Interpretation of the Plan. HEBP will receive and review claims for benefits under the Plan. The operation and administration of the Plan require uniformity regarding the intent and the interpretation of the Plan’s provisions. The Plan Administrator has full and complete authority and discretion to make decisions regarding Plan provisions and to determine questions of eligibility and benefits. Draft HEBP assumes only the authority and discretion as given by the Plan Administrator to interpret benefits based on medical necessity, allowable amount, or experimental/investigational guidelines that are in accordance with the provisions in Member’s Plan. Any decision that is not arbitrary or capricious shall be final and conclusive, subject to any right to appeal a determination to the Plan Administrator. On occasion, HEBP, in its role as Claims Administrator, may deny all or part of submitted claims. HEBP will provide a full and fair review of any determination of a claim, any determination of a request for precertification, and any other determination made as the Claims Administrator in accordance with the benefits and procedures detailed in Member’s Plan. HEBP will use its best efforts, consistent with administrative practices and any procedures established in writing between HEBP and the Plan and consistent with industry standards, to accurately process all claims.