Summary of Benefits
		Election of Coverage and Eligibility Provisions
		Comprehensive Medical Benefits
		Income Protection Benefit
		Dental Benefit
		Dental Schedule of Benefits
		Prescription Drug Benefit
		Vision Benefit
		Life Insurance & AD&D Benefit
		General Exclusions and Limitations

		Summary of Benefits
		Election of Coverage and Eligibility Provisions
		Comprehensive Medical Benefits
		Prescription Drug Benefit
		General Exclusions and Limitations

		How to File a Claim
		When to Call Us
		Request an ID Card
		Continuation of Coverage (COBRA)
		Claim Appeal Procedure
		Coordination of Benefits
		Privacy Practices
		Health Benefits Plan Claim Procedures
		Summary of the Cafeteria Plan
		Forms & Publications

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CLAIM APPEAL PROCEDURE

If you believe you have been improperly denied benefits provided for under the Plan, you are entitled to a full and fair review of your claim.

The procedure to follow to file an appeal is summarized here. For more detailed information refer to the Health Benefits Plan Claim Procedures page of this website.

If your initial claim is denied, you will be given a written explanation within the period of time allowed by law. The explanation will provide:

• the specific reason(s) for the denial, including a reference to the specific Plan provision on which the denial is based;
• a description of any additional material or information required for you to show you are entitled to benefits;
• an explanation of the procedure to be followed if you do not agree with the denial, including a statement of your right to file suit under ERISA, if you file an appeal and it is denied;
• any internal rule, guideline, protocol or other similar criterion that was used in making the denial decision, or a statement that this information will be provided upon request;
• an explanation of any scientific or clinical judgement for the denial decision if it was based on a medical necessity, experimental treatment or other exclusion or limit, or a statement that this information will be provided upon request; and
• if your claim is an urgent claim, a description of the expedited review process available to you (in the case of an urgent care claim, we may provide this explanation orally and give you a written explanation later).

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