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Health Fund

Denial Notices

Any notice of an adverse benefit decision will include the following:

  • The specific reason or reasons for the adverse determination;
  • Reference to the Fund's provisions on which the determination was based;
  • A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why the information is necessary;
  • A description of the Fund's review procedures, the time limits applicable to such procedures, and the claimant's right, at no charge, to have reasonable access to and to obtain copies of all relevant documents upon request, and a statement of the claimant's right to bring a civil action under ERISA Section 502(a) following an adverse determination on review;
  • If an internal rule or guideline was applied in making the determination, a statement that the rule will be provided free of charge upon request;
  • If the determination is based on a medical necessity or experimental exclusion, a statement that an explanation of the scientific or clinical judgment applied to make the determination will be provided free of charge upon request;
  • If the determination affects a claim for urgent health care, a description of the expedited review process applicable to such claims;
  • Information identifying the claim involved including the date of service, the health care provider, the claim amount, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning;
  • The reason(s) for the adverse benefit determination including the denial code and its corresponding meaning, as well as a description of the Plan's standard, if any, that was used to deny the claim at issue, and, in the case of final adverse benefit determinations, the description of the discussion of the decision;
  • A description of the available internal appeals and review processes, including information regarding how to initiate an appeal; and
  • The contact information and availability of any applicable offices of health insurance consumer assistance or ombudsman established under PPACA to assist you with the internal claims and appeals processes.

In addition, the Fund will provide you (free of charge) with any new or additional evidence that was considered, relied upon, or generated by the Fund or the Claims Administrator in connection with the claim, as well as any new or additional rationale for a denial at the internal appeals stage, and a reasonable opportunity for you to respond to such new evidence or rationale before the Plan makes a final determination of the claim on review or appeal.