2017 011 Ordinance - Laserfiche WebLink

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8.02. Required information Each Participant's claim for benefits shall contain a written statement containing the following information: (a) the person or persons on whose behalf Eligible Medical or Prescription Expenses have been incurred; (b) the nature of the expenses so incurred; and (c) the amount of the requested reimbursement; (d) a statement that such expenses have not otherwise been paid through insurance or reimbursed from any other source. The above information can be provided by submitting a copy of the employer sponsored fully insured programs Explanation of Benefits Statement which provides detailed information of the specific claim for benefits. The Plan may require, in addition to the Explanation of Benefits Statement, a copy of the medical provider statement which corresponds to the claim for benefit request. 8.03. Method and contents of denial notices Any Notice of the denial of a Claim for benefits shall be given the Claimant or his duly Authorized Representative either in written form or as an Electronic Notice. The Denial Notice must include: (a) the specific reason or reasons for the Adverse Benefit Determination; (b) reference to the specific plan provisions on which the determination is based; (c) a description of any additional material or information necessary for the Claimant to perfect the claim and an explanation of why such material or information is necessary; (d) a description of the review procedures set out in this Section XIII and the time limits applicable to such procedures, including a statement of the Claimant's right to bring a civil action under ERISA sect. 502(a) following an Adverse Benefit Determination on review; and (e) if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the Claimart upon request. 8.04. Appealing an adverse benefit determination Within one-hundred eighty (180) days after the receipt by the Claimant of written notification of the denial (in whole or in part) of his Claim, the Claimant or his duly Authorized Representative, upon written application to the Plan Administrator, in person or by certified mail, postage prepaid, may request a review of such denial, may review pertinent documents, and may submit issues and comments in writing. Ma~eld Village HRA Plan 0117.doc 12