Filing A Claim For Benefits

When you are reasonably sure you are eligible to receive benefits under any of these plans, you may request a claim form from your local Human Resources representative. Claim forms may also be available on-line via the Company intranet.

Under certain health care plans you may not need to file a claim to receive benefits. For details about when you need to file a claim, refer to the applicable benefit plan description provided elsewhere in your Benefits Handbook.

All claims submitted to the Plan Administrator must be on forms provided by the Plan Administrator unless forms are not currently available, in which case you may simply supply the appropriate party with a written statement outlining proof and extent of loss. (HMSA requires that all claims be submitted on an HMSA or universal claim form; note, too, that HMSA does not have claim forms for out-of-area claims.)

Complete the claim form according to the directions and return it to the appropriate Plan Administrator (or to Benefits Administration if directed to do so) within the timeframe requested.

The Plan Administrator will review the claim to determine whether or not benefits are payable in accordance with the terms and provisions of the group plan. Under special circumstances, the Plan Administrator may require additional review time, in which case you will receive written notice informing you of the need for an extension. The Plan Administrator may require a medical examination or additional information to make a determination of your claim. If additional information is required, you will receive a request in writing, indicating what information is needed and the reason.

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What If Your Benefits Are Denied?

If your claim for benefits is denied in whole or part, the Plan Administrator will provide you with written notice of the denial. For purposes of this section, "denial" means an adverse benefit determination where the full amount of expenses has not been paid by the plan.

Each written notice of denial will:

• State the specific reasons for the denial the claim.

• Reference any applicable provisions upon which the denial is based.

• Describe additional material or information necessary to complete the claim and why such information is necessary.

• Describe plan procedures and time limits for appealing the determination, your right to obtain information about those procedures, and—if you have exhausted the plan's appeal procedures—the right to sue in federal court. If you do not request an appeal in writing on time, you will lose your right to appeal your denial or file a suit in court.

• Disclose any internal rule, guidelines, protocol, or similar criterion relied on in making the denial (or state that such information will be provided free of charge upon request).

• If the denial is based on medical necessity or experimental treatment, the plan will provide an explanation of the scientific or clinical judgment for the decision, applying plan terms to your medical condition (or state that such information will be provided free of charge upon request).

• For urgent claims, the denial notice will include a description of the expedited review process applicable to such claims. This denial may be given orally, provided that a written or electronic notification is furnished to you no later than three days after the verbal notification.

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Appeals

If you believe your claim was denied in error, you may appeal this decision to the plan. You have 180 days after receiving the claim denial to appeal the plan's decision. If you do not request an appeal within this timeframe, you will lose your right to appeal under the plan. You may submit written comments, documents, or other information to support your appeal and request access to all relevant documents free of charge. The review of the claim denial will take into account all new information, whether or not presented or available at the initial claim review, and will not be influenced by the initial claim decision.

A person who is not involved in the initial claim determination will conduct the appeal review and such person will not work under the original decision maker's authority. If your claim was denied on the grounds of medical judgment, the plan will consult with a health professional with appropriate training and experience. This health care professional will not be the individual who was consulted during the initial determination or work under their authority. If the advice of a medical or vocational expert was obtained by the plan in connection with the denial of your claim, we will provide you with the names of each such expert, regardless of whether the advice was relied upon.

If your claim involves urgent care, a request for an expedited appeal may be submitted orally or in writing and all necessary information shall be transmitted between the plan and you by telephone, fax, or other similar method.

If your appeal is denied, the denial notice will contain the following information:

• The specific reasons for the appeal determination.

• A reference to the specific plan provisions on which the determination was based.

• A statement that you are entitled to receive upon request, and without charge, reasonable access to or copies of all document, records, or other information relevant to the determination.

• A statement describing any voluntary appeal procedures offered by the plan and your right to obtain information about these procedures.

• A statement describing your right to bring a civil lawsuit under federal law. If you do not first exhaust the plan's appeal procedures, you will lose your right to file a suit in court.

• A statement disclosing any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or a statement that such information will be provided free of charge upon request).

• If the denial is based on medical necessity or experimental treatment, an explanation of the scientific or clinical judgment for the determination, applying plan terms to your medical condition (or state that such information will be provided free of charge upon request).

• A statement that "You or your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office and your state insurance regulatory agency."

The appeal determination notice may be provided in written or electronic form. Electronic notices will be provided in a form that complies with any applicable legal requirements.

In addition, as required under California law, California employees that have a complaint concerning a claim under their health plans may seek assistance by contacting the:

You may also call the California Department of Managed Health Care at  888-466-2219.

If, after following these steps, your claim still has not been resolved to your satisfaction, you should contact your local Human Resources representative; you may also serve legal process upon the Plan Administrator.

Although A&B anticipates very few problems of this kind, you should be aware of the channels that are open to you.

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Claim Deadlines For Health Care Benefits

The following claim review and appeal timeframes are maximums. The plan may notify you—and you may respond with requested information—earlier than these maximums. However, if you (or your provider) do not provide the requested information within the specified timeframes, your claim will be denied.

For purposes of this section, health care includes medical, dental, vision, prescription drug and mental health/substance abuse benefits. Claims are categorized as follows:

Urgent claim. Claims for treatment of conditions that could jeopardize your life, health, or ability to regain maximum function, or would subject you to severe pain. If a physician determines the condition is urgent, the plan must accept the physician's determination.

Pre-service claim. Claims that require notification or approval before services are rendered.

Post-service claim. Claims where the services have already been provided to the patient.

Health Care Claim Review Timeframes For Claims Incurred On Or After January 1, 2003
Urgent Claim
If your claim is complete
Plan initially denies your claim	72 hours after receiving the claim.
Your appeal must be requested	180 days after receiving the denial.
Plan makes a final appeal decision	72 hours after receiving your request for an appeal.
If your claim is incomplete or you failed to follow the correct claims procedure
Plan notifies you how to complete or correctly submit your claim	24 hours after receiving the claim.
You complete your claim	48 hours after receiving the notice.
Plan responds to your revised claim	48 hours after your deadline to complete the claim, or after receiving your completed claim, if sooner.
If denied, your appeal must be made	180 days after receiving the denial.
Pre-Service Claim
If your claim is complete
Plan initially denies your claim	15 days after receiving the claim.
Your appeal must be requested	180 days after receiving the denial.
Plan makes final appeal decision:
If plan has one level of appeal	30 days
If plan has two levels of appeal	15 days. The plan must notify you within the first 15 days for the first level decision; you have 60 days to request a second level of appeal; the plan then has 15 days following your request to notify you of the second level appeal decision.
If your claim is incomplete or you failed to follow the correct claims procedure
Plan notifies you of how to correctly submit your claim	Five days after receiving the claim.
Plan notifies you of missing information that is needed to process the claim and may request a 15-day extension	15 days after receiving the claim. The notice will indicate if an extension is needed. Your claim will be pended until all of the required information is provided. Note: If a claim is initially submitted incorrectly and later found to be incomplete, the 15-day notification requirement begins on the date that the claim is correctly submitted, not on the initial date of the receipt.
You complete your claim (or your provider completes your claim)	45 days after receiving the notice of extension.
Plan responds to your revised claim	15 days after receiving the information. If the extension was requested sooner than the 15-day notification period stated above, the plan has additional time to process your claim, up to a maximum of 30 days. For example, if the plan notified you of needed information within five days, it has 25 days to process your claim once all of the information is received. The time the plan waits for claimant information is not counted in this total.
If denied, your appeal must be made	180 days after receiving the denial.
Plan makes final appeal decision:
If plan has one level of appeal	30 days.
If plan has two levels of appeal	15 days. The plan must notify you within the first 15 days for the first level decision; you have 60 days to request a second level of appeal; the plan then has 15 days following your request to notify you of the second level appeal decision.
Post-Service Claim
If your claim is complete
Plan initially denies your claim	30 days after receiving the claim.
Your appeal must be requested	180 days after receiving the denial.
Plan makes final appeal decision:
If plan has one level of appeal	60 days.
If plan has two levels of appeal	30 days. The plan must notify you within the first 30 days for the first level decision; you have 60 days to request a second level of appeal; the plan then has 30 days following your request to notify you of the second level appeal decision.
If the plan needs further information or an extension
Plan notifies you that additional information is needed to complete your claim	30 days after receiving the claim. The claims administrator will notify you during this period if a 15-day extension is needed.
You complete your claim (or your provider completes your claim)	45 days after receiving the notice or notice of extension.
Plan responds to your revised claim	15 days after receiving the information. If the extension was requested sooner than the 30-day notification period stated above, the plan has additional time to process your claim, up to a maximum of 45 days. For example, if the plan notified you of the needed information within 10 days, it has 35 days to process your claim once all of the information is received. The time the plan waits for claimant information is not counted in this total.
If denied, your appeal must be made	180 days after receiving the denial.
Plan makes final appeal decision:
If plan has one level of appeal	60 days.
If plan has two levels of appeal	30 days. The plan must notify you within the first 30 days for the first level decision; you have 60 days to request a second level of appeal; the plan then has 30 days following your request to notify you of the second level appeal decision.

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