Benefit Plans Administrative Services BPAS 3/9/2020

"Adverse"means: • A denial, reduction, or termination of a benefit; • A failure to provide or make payment(in whole or in part) for a benefit; or • A rescission of coverage under the Plan, which is a cancellation or discontinuance of coverage under the Plan that has retroactive effect other than a cancellation or discontinuance attributable to a failure to timely pay or make required premiums or contributions toward coverage. (b) Adverse Decision. For adverse claim determinations,the notification shall at a minimum: • Include information sufficient to identify the claim involved, including the date of service, the identity of the health care provider, and the claim amount, and to inform the claimant of the right to receive, upon request, the diagnosis and treatment codes (if any) and their corresponding meanings upon request; • State the specific reason(s) for the determination, including the denial code (if any)and its corresponding meaning,and describe the Plan's standard, if any, used to make the determination; • Reference specific Plan provision(s) upon which the determination is based; • Describe additional material or information necessary to complete the claim and why such information is necessary; • Describe the internal appeals and external review processes (if any) available under the Plan, including how to initiate an appeal and the procedures and time limits applicable to an appeal; • Disclose any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or state that such information will be provided free of charge upon request); • Where the decision involves scientific or clinical judgment, disclose either (1) an explanation of the scientific or clinical judgment applying the terms of the Plan to claimant's medical circumstances, or(2) a statement that such explanation will be provided at no charge upon request; and • Disclose the availability of and contact information for any applicable office of health insurance consumer assistance or ombudsman established to assist individuals with the internal claims and appeals and external review processes (if any). Notice of the adverse determination may be provided in written or electronic form. Electronic notices will be provided in a form that complies with applicable legal requirements. (c) Not Adverse Decision. For claim determinations that are not adverse, notice will be provided that informs the claimant or the claimant's Authorized Representative the claim has been accepted. ©2017 Hitesman&Wold, P.A. 17 Funded Post-Employment HRA Basic Plan Document(Single Employer Non-ERSA)