Benefit Plans Administrative Services BPAS 3/9/2020

considered. The decision shall be based upon that information plus the terms of the Plan and past interpretations of the same and similar Plan provisions. The Plan may rely upon protocols,guidelines, or other criterion. (f) 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 whether the decision is adverse or not 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. "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. (g) Adverse Decision. For adverse appeal determinations, the notification shall reflect at least the following: • 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; • Contain a discussion of the determination, including the specific reason(s) for the determination, the denial code (if any) and its corresponding meaning, and the Plan's standard, if any, used to make the determination; • Reference specific Plan provision(s) upon which the determination is based; • Describe the external review process (if any) available under the Plan; • Disclose any internal rules, 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); • A statement indicating entitlement to receive upon request, and without charge, reasonable access to or copies of all documents, records or other information relevant to the determination; • 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 external review process (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. (h) 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 decision ©2017 Hitesman&Wold,P.A. 19 Funded Post-Employment HRA Basic Plan Document(Single Employer Non-ERSA)