Benefit Plans Administrative Services BPAS 3/9/2020

ARTICLE VI. CLAIMS DETERMINATIONS AND REVIEW OF DENIED CLAIM The following procedures apply: 6.1 General Provisions. All claims and appeals will be adjudicated in a manner so that the independence and impartiality of the persons involved in making the determination are ensured. Decisions regarding hiring, compensation, termination, and similar matters with respect to any individual involved in the determination (e.g., a claims adjudicator or medical expert) shall not be based upon the likelihood that the individual will support a denial of benefits. 6.2 Initial Claim Determination. (a) Time Frame for Decision. The Plan must determine the claim within thirty(30) days of receipt of the claim. (b) Extension of Time. If the Plan is not able to determine the claim within this time period due to matters beyond its control, the Plan may take an additional period of up to fifteen (15) days to determine the claim. If this additional time will be needed, the Plan must notify the claimant or the claimant's Authorized Representative prior to the expiration of the initial thirty (30) day time period for determining the claim. This extension is only available once. Notification: The notification of the need for the extension must include a description of the"matters beyond the Plan's control"that justify the extension and the date by which a decision is expected. (c) Incomplete Claims. There is no special rule if a claim is incomplete. Incomplete claims can be addressed through the extension of time described above. If the reason for the extension is the failure to provide necessary information and the claimant is appropriately notified, the Plan's period of time to make a decision is"tolled." Tolling: The period of time in which the Plan must determine a claim is suspended from the date upon which notification of the missing necessary information is sent until the date upon which the claimant responds. Notification: For this purpose, notification can be made orally to the claimant or the health care professional, unless the claimant requests written notice. The notification will include a time frame in which the necessary information must be provided. Once the necessary information has been provided, the Plan must decide the claim within the extension described above. If the requested information is not provided within the time specified,the claim may be decided without that information. 6.3 Decision. (a) Notification of Decision. Written (or electronic) notification of the Plan's determination must be provided to the claimant or the claimant's Authorized Representative. Such notification must be provided only where the decision is adverse. The notification will be provided in a culturally and linguistically appropriate manner in accordance with 45 CFR § 147.136,to the extent such regulation applies to the Plan. ©2017 Hitesman&Wold,P.A. 16 Funded Post-Employment HRA Basic Plan Document(Single Employer Non-ERSA)