Xxxxxx and Content of Appeal Notification. AvMed will provide a Claimant with written or electronic notification of its benefit determination upon review. In the case of an Adverse Benefit Determination, AvMed will notify both the Member and the Health Professional, and the notification will set forth all of the following as appropriate, in a manner calculated to be understood by the Claimant:
a. the specific reasons for the Adverse Benefit Determination;
b. reference to the specific Contract provisions on which the Adverse Benefit Determination is based;
c. a statement that the Claimant is entitled to receive reasonable access to, and copies of, any Relevant Documents, upon request and free of charge;
d. a statement describing any voluntary appeal procedures offered by XxXxx and the Claimant’s right to obtain information about such procedures, and a statement of the Claimant’s right to bring an action under ERISA Section 502(a) when applicable;
e. any internal rule, guideline, protocol, or other similar criterion relied upon in making the Adverse Benefit Determination; or a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge to the Claimant upon request;
f. if the Adverse Benefit Determination is based on whether a treatment or service is Experimental or Investigational, or not Medically Necessary, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the Member’s medical circumstances; or a statement that such explanation will be provided free of charge upon request.
