Reso 2010-1529 - Laserfiche WebLink

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) 16.06 Manner and content of initial claims determination notification. AvMed shall provide a Claimant with written or electronic notification of any Adverse Benefit Determination. The notification shall set forth, in a manner calculated to be understood by the Claimant, the following: ') The specific reasons for the Adverse Benefit Determination. Reference to the specific Plan provisions on which the determination is based. A description of any additional material or information necessary for the Claimant to perfect the Claim and an explanation of why such material or irtforrnation is necessary. A description of AvMed's review procedures and the time limits applicable to such procedures, including, when applicable, a statement of the Claimant's right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974, as amended (ERISA), following an Adverse Benefit Determination on final review. 16.06.05 If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determination, either the specific rule, guideline, protocol, or other similar criterion or a statement that such rule, guideline, protocol or other similar criterion was relied upon in rnaking the Adverse Benefit Determination and that a copy shall be provided free of charge to the Claimant upon request. 16.06.06 If the Adverse Benefit Determination is based on whether the treatment or service is experimental and/or investigational or not Medically Necessary, either an explanation of the scientific or clinical judgment for the determination, applying the teffilS of the Plan to the Claimant's medical circumstances, or a staternent that such explanation shall be provided free of charge upon request. 16.06.07 In the case of an Adverse Benefit Determination involving an Urgent Care Clairn, a description of the expedited review process applicable to such Claim. 16.07 Review procedure upon appeal. AvMed's appeal procedures shall include the following substantive procedures and safeguards: 16.06.01 16.06.02 16.06.03 16.06.04 -j ) 16.07.01 Claimant may submit written comments, documents, records, and other information relating to the Claim. 16.07.02 Upon request and free of charge, the Claimant shall have reasonable access to and copies of any Relevant Documents. 16.07.03 The appeal shall take into account all comments, documents, records, and other information the Claimant submitted relating to the Claim, without regard to whether such information was submitted or considered in the initial Adverse Benefit Determination. 16.07.04 The appeal shall be conducted by an appropriate named fiduciary of AvMed who is neither the individual who made the initial Adverse Benefit Determination nor the subordinate of such individual. Such person shall not defer to the initial Adverse Benefit Determination. 16.07.05 In deciding an appeal of any Adverse Benefit Determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, medication, or other itern is experimental and/or investigational or not Medically Necessary, the appropriate named fiduciary shall consult with a Health Professional who has appropriate training and experience in the field of medicine involved in the medical judgment. 16.07.06 The appeal shall provide for the identification of medical or vocational experts whose advice was obtained on behalf of AvMed in connection with a Claimant's Adverse Benefit 43 A V -Gl 00-2009 MP-5319 (10/09)