Administrative Information
 

Claim Denial and Appeal

If your claim for benefits under any of the benefit plans described in this Summary Plan Description is wholly or partially denied, you will receive a written notification of the denial and the reasons for it. This notice will include:

  • the specific reasons for the denial;
  • the plan provisions on which the denial is based;
  • a description of any additional material that is required; and
  • an explanation of the plan’s appeal procedure. 

You should follow the procedures outlined in this section for appealing a denied claim.

CLAIM ADMINISTRATORS
Your appeal of a denied claim should be addressed to the applicable plan’s Claim Administrator. The following table shows the name and address of each Claim Administrator:

Plan or Program Claim Administrator’s Address for Filing Appeal

Medical Plans

Tufts Health Plan
Attn: Appeals and Grievances Department
705 Mount Auburn Street
PO Box 9193
Watertown, MA 02471-9193
BeWell Center Onsite Clinic Tufts Health Plan
Attn: Human Resources
705 Mount Auburn Street
Watertown, MA 02472-1508
Dental Plan Delta Dental of Massachusetts
PO Box 9695
Boston, MA 02114-9695
Attn: Grievances
EyeMed Vision Care Plan   EyeMed Vision Care, L.L.C.
Quality Assurance
4000 Luxottica Place
Mason, OH 45040
Fax: 513-492-3259
Tufts Associated Helath Plan, Inc., Disability Plan (STD) and Tufts Associated Health Plan, Inc., Disability Plans (LTD)

Unum Life Insurance Company of America
2211 Congress Street
Portland, Maine 04122

Long-Term Care Insurance Plan
(applies only to employees enrolled in the plan prior to 12/31/2011)

John Hancock Life Insurance Company (U.S.A.)
Group Long-Term Care
PO Box 111
Boston, MA 02117
Attn: Long-Term Care Claims
Salary Continuance Plan for Full-Time Employees classified as VPs & Above Tufts Health Plan
705 Mount Auburn Street
Watertown, MA 02472
Attn: VP HR

Basic and Optional Life Insurance for Full-Time Employees

Optional Employee Term Life Insurance for Part-Time Employees

Basic and Voluntary Accidental Death and Dismemberment (AD&D) Plan
Unum Life Insurance Company of America
2211 Congress Street
Portland, Maine 04122
Attn: Appeals Team
Flexible Spending Account Plan ADP Benefit Services
2575 Westside Parkway, Suite 500
Alpharetta, GA 30004-3852

Group Legal Plan

ARAG Group 
400 Locust Street, Suite 480
Des Moines, IA 50309
Attn: Claim Appeal
Tufts Health Plan Adoption Assistance Plan Tufts Health Plan
705 Mount Auburn Street
Watertown, MA 02472
Employee Assistance Program E4 Health
55 Cedar St. #100
Providence, RI 02903


MEDICAL PLAN CLAIM DENIAL AND APPEAL

This section describes:

  • the time frame(s) for receipt of a medical plan claim denial; and
  • the procedures for appealing a denied claim.

RECEIPT OF CLAIM DENIAL
If your claim for benefits under your Tufts Health Plan medical plan is denied, the Claim Administrator will send you a written notice of its decision and the reasons for it. 

The time frame for receipt of a medical plan claim denial will depend on the nature of the claim:

Urgent Care Claim: An urgent care claim is a claim that has to be decided more quickly because using the normal time frames for decision-making could seriously jeopardize the life or health of the patient or the ability of the patient to regain maximum function or, in the judgment of a physician, would subject the patient to severe pain that could not be adequately managed without the care or treatment that is the subject of the claim.

For urgent care claims, the Claim Administrator will notify you of the determination, whether adverse or not, as soon as possible considering the urgency of your medical situation but no later than 72 hours after receipt of the claim.

Pre-Service Claim: A pre-service claim is a claim for a benefit that must be approved before receiving medical care – for example, precertification of an out-of-network hospital admission.

For pre-service claims, the Claim Administrator will notify you of the determination, whether adverse or not, within a reasonable period of time appropriate to the medical circumstances, but no later than fifteen (15) days after receipt of the claim. This period may be extended by up to fifteen (15) days, if the Claims Administrator:

  • determines that an extension is necessary because of matters beyond the Claim Administrator’s control; and
  • notifies you within the initial 15-day period of the circumstances requiring the extension and the date by which the Claim Administrator expects to render a decision.

If such an extension is necessary because you do not submit the information necessary to decide the claim, the notice of extension will specifically describe the required information. You will be given at least forty-five (45) days from receipt of the notice within which to provide the specified information.

Post-Service Claim: A post-service claim involves the payment or reimbursement of costs for medical care that has already been provided.

For post-service claims, the Claim Administrator will notify you of an adverse determination within a reasonable period of time, but no later than thirty (30) days after receipt of the claim. This period may be extended by up to fifteen (15) days if the Claim Administrator determines that an extension is necessary because of matters beyond the Claims Administrator’s control and notifies you, within the initial 30-day period, of the circumstances requiring the extension and the date by which the Claim Administrator expects to render a decision. You will be given at least forty-five (45) days from receipt of the notice within which to provide the specified information.

Concurrent Care Claim: A concurrent care claim involves a claim for which the plan has previously approved an ongoing course of treatment over a period of time or a specific number of treatments, and either the Claim Administrator later reduces or terminates coverage for those treatments before the end of that period or you request to extend the course of treatment beyond the approved period of time or number of treatments.

Concurrent care claims may fall under the following categories, and different notice and appeal time frames apply:

  • If an ongoing course of treatment will be reduced or terminated, you will be notified sufficiently in advance so that you have the opportunity to appeal and obtain a decision on appeal before the benefit is reduced or terminated.
  • If you request an extension of ongoing treatment in an urgent circumstance, you will be notified as soon as possible given the medical exigencies, but no later than 24 hours after the Claim Administrator receives your claim, as long as the request to extend treatment is submitted to the plan at least 24 hours before the end of the prescribed time period or number of treatments.
  • If you request an extension of ongoing treatment in a non-urgent circumstance, the request will be considered a new claim and decided according to post-service or pre-service time frames, whichever applies.

INTERNAL APPEALS PROCESS

Appealing a Denied Claim
A request for coverage that was denied as specifically excluded in your medical plan’s Description of Benefits or for coverage that was denied based on medical necessity determinations are reviewed as appeals through the Internal Appeals Process.

You may designate in writing someone to act on your behalf. You have 180 days from the date you were notified of the denial of benefit coverage or claim payment to file your appeal. 

You can submit a verbal appeal of a benefit coverage decision to a Tufts Health Plan Member Specialist, who will forward it to the Appeals and Grievances Department. You can also submit a written appeal to the address listed above. Tufts Health Plan encourages you to submit your appeal in writing to accurately reflect your concerns.

Your letter should include: 

  • your complete name and address;
  • your ID number and suffix;
  • a detailed description of your concern; and
  • copies of any supporting documentation.

Within five (5) business days of the receipt of your written appeal, a Tufts Health Plan Appeals and Grievances Analyst will send an acknowledgment of receipt to you and if appropriate, a request for authorization for the release of medical and treatment information.

Within 48 hours of receipt of a verbal appeal, a Tufts Health Plan Appeals and Grievances Analyst will summarize your request for an appeal and send a copy to you. This summary will serve as the acknowledgment of receipt of your appeal and if appropriate, will include a request for authorization for the release of medical and treatment information.

Once you have signed and returned the authorization for the release of medical and treatment information to Tufts Health Plan, the Appeals and Grievances Analyst will document the date of receipt and coordinate the investigation of your appeal. In the event that you do not sign and return the authorization for the release of medical and treatment information to Tufts Health Plan within thirty (30) calendar days of the day you requested a review of your case, Tufts Health Plan may, in its discretion, issue a resolution of the appeal without reviewing some or all of your medical records.

The Tufts Health Plan Benefits Committee will review appeals concerning specific exclusions and make determinations. The Tufts Health Plan Appeals Committee will make utilization management (medical necessity) decisions. If your appeal involves an adverse determination (medical necessity determination), it will be reviewed by a medical director and/or a practitioner in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review. The medical director and/or practitioner will not have previously reviewed your case.

If the case involves an adverse determination (medical necessity determination) and you would like to address the Committee, you should contact the Appeals and Grievances Analyst who is handling your appeal. If you ask to attend the meeting, Tufts Health Plan will notify you of the date and time. You will have access to any medical information and records relevant to your appeal which are in the possession and control of Tufts Health Plan. The time limits of this process will be waived or extended by a mutual written agreement between you or your authorized representative and Tufts Health Plan.

The Appeals and Grievances Analyst will notify you in writing of the Tufts Health Plan’s decision on your appeal, within no more than thirty (30) calendar days of the receipt of your appeal. The decision letter will include the specific reasons for the decision and references to the pertinent plan provisions on which the decision is based.

Tufts Health Plan maintains records of each inquiry made by a Member or by that Member’s authorized representative.

Expedited Appeals
Tufts Health Plan recognizes that there are circumstances that require a quicker turnaround than the thirty (30) calendar days allotted for the standard appeals process.  Tufts Health Plan will expedite an appeal when there is an ongoing service about to terminate or a service to be delivered imminently whereby a delay in treatment would seriously jeopardize your life and health or jeopardize your ability to regain maximum function. If your request does not meet the guidelines for an expedited appeal, Tufts Health Plan will explain your right to use the standard appeal process.

If your request meets the guidelines for an expedited appeal, it will be reviewed by a medical director and/or practitioner in a same or similar specialty that typically manages the medical condition, procedure or treatment under review. The medical director and/or practitioner will not have previously reviewed your case.

Tufts Health Plan will notify you by telephone within one (1) business day after receiving the information necessary to conduct your appeal, but no later than 72 hours after Tufts Health Plan’s receipt of the request.

External Review
In most cases, if you do not agree with the Appeals decision, you or your authorized representative has the right to request an independent, external review of the decision. Should you choose to do so, send your request within four months of your receipt of written notice of the denial of your appeal to:

Tufts Health Plan
Attn: Appeals & Grievances Department
705 Mount Auburn Street
Watertown, MA 02471-9193
Fax: 617-972-9509

In some cases, you may have the right to an expedited external review. An expedited external review may be appropriate in urgent situations. Generally, an urgent situation is one in which your health may be in serious jeopardy, or, in the opinion of your physician, you may experience pain that cannot be adequately controlled while you wait for a decision on your appeal.

If you request an external review, an independent organization will review the decision and provide you with a written determination. If this organization decides to overturn the Appeal decision, the service or supply will be covered under the plan.

If you have questions...
If you have questions or need help submitting a grievance or an appeal, please call a Tufts Health Plan Member Specialist at 1-800-462-0224, ext. 53585 for assistance.

BEWELL CENTER ONSITE CLINIC GRIEVANCE AND COMPLAINT PROCESS

Internal Grievance/Complaint Process: You may file a grievance or complaint by phone, in person, by mail, or by electronic means to Human Resources. 

If an oral or written grievance or complaint is received, Human Resources will send a written acknowledgement of receipt of your grievance to you or your authorized representative, if any, within fifteen (15) business days of receipt.

Human Resources will provide you or your authorized representative, if any, a written response to your grievance or complaint within thirty (30) business days of receipt of the oral or written grievance.

Written Decision
In the event that your grievance or complaint involves an adverse determination, Human Resources’ written response will include an explanation of the adverse determination which identifies the specific information upon which the adverse determination was based. 

An appeal concerning denied payment of a claim should be filed with your medical insurance company.

DENTAL PLAN CLAIM DENIAL AND APPEAL

The Claim Administrator will process your dental plan claim within 30 working days of the date that it receives all necessary information. An adverse determination will occur if your claim is partially or wholly rejected.

You may file a grievance with the Claim Administrator if you receive an adverse determination of your claim. If the Claim Administrator’s response is not satisfactory to you, you may appeal the adverse determination.

Internal Grievance Process: You may file a grievance by phone, in person, by mail, or by electronic means. If an oral grievance has been presented, the Claim Administrator will convert your grievance into writing and a copy will be sent to you within ten (10) business days of receipt, unless this time frame has been waived or extended by mutual written agreement between both you and Delta Dental Plan.

The Claim Administrator will send a written acknowledgement of our receipt of your grievance to you or your authorized representative, if any, within fifteen (15) business days of receipt. The only exception is where an oral grievance has been converted to writing. In this case, the acknowledgement will be sent within ten (10) business days of receipt unless this time period has been waived or extended.

The Claim Administrator will provide you or your authorized representative, if any, a written resolution of a grievance within thirty (30) business days of receipt of the oral or written grievance.

Written Decision
In the event that your grievance involves an adverse determination, the Claim Administrator’s written response will include a substantive clinical justification that is consistent with generally accepted principles of professional dental practice and will:      

  • identify the specific information upon which the adverse determination was based; and
  • reference and include applicable clinical practice guidelines and criteria.

Reconsideration
The Claim Administrator will provide you with the opportunity to have a final decision reconsidered where relevant information is received too late to review within the thirty (30) business day time limit or is not received but is expected to become available within a reasonable period.

The Claim Administrator will review a reconsideration and provide a written response to you as soon as possible following receipt of the additional information. The Claim Administrator will provide this response no later than thirty (30) business days following your request for reconsideration. 

EYEMED VISION CARE PLAN CLAIM DENIAL AND APPEAL

Member Complaint procedure:
If you are dissatisfied with the services provided by an EyeMed Vision Care provider, you may write to EyeMed at the address shown below or call the EyeMed Vision Care Member Services toll free telephone number at 1-877-829-5067. If you write, the address is:

EyeMed Vision Care, L.L.C.
Attention: Quality Assurance
4000 Luxottica Place
Mason, OH 45040
Fax: 513-492-3259

If you call, the EyeMed Vision Care Member Services representative will log the telephone call and attempt to reach a resolution. If a resolution cannot be reached during the telephone call, or you are not satisfied with the resolution, you may file a written complaint to the address listed above.  All written complaints will be acknowledged within three business days and resolved within 30 calendar days.

If you remain dissatisfied with the complaint resolution, you may file a written complaint appeal within 30 calendar days of receipt of the complaint resolution. All written complaint appeals will be acknowledged in three business days and resolved within 30 calendar days.  If you remain dissatisfied with the complaint appeal resolution, you and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory Agency.

Appealing Denied Claims:
As part of the claims administration process, EyeMed Vision Care (via First American Administrators, Inc., a wholly-owned subsidiary of EyeMed) will pay claims for benefits due under the Plan, provide written explanations of the reasons for denied claims, and handle requests for reviews of denied claims.  If your claim is denied in whole or in part, you have the right to have the claim reviewed and reconsidered.

Please send a written request to review the claim within 180 days of the denial to:

EyeMed Vision Care, L.L.C.
Attention: Claim Appeals
4000 Luxottica Place
Mason, OH 45040
Fax: 513-492-3259

Your written letter of appeal should include: 

  • the applicable claim number or Explanation of Benefits, if applicable;
  • the item of your coverage that you feel was misinterpreted or inaccurately applied; and
  • any additional information that you believe will help EyeMed Vision Care complete its review of your appeal, such as documents, records or comments.

EyeMed Vision Care will review your appeal for benefits and notify you in writing of its decision, as well as the reasons for the decision, within 30 calendar days of receipt of the appeal. 

EyeMed’s appeal decision notifications include the reasons for the decision, a reference to specific plan provisions, a statement of the specific medical determination, clinical basis and/or contractual criteria used to make the decision and the specialization of any physician or other Provider consulted, along with a notice of voluntary alternative dispute resolution options.

For more information on your rights and how to file a formal appeal under the Employee Retirement Income Security Act of 1974, as amended (ERISA), refer to the appropriate section of your Summary Plan Description.

You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory Agency. You are entitled to receive, free of charge, upon request, access to and copies of documents, records and other information relevant to your claim.

DISABILITY PLAN CLAIM DENIAL AND APPEAL

If your claim for Short-Term or Long-Term Disability plan benefits is wholly or partially denied, the Claim Administrator will notify you within 45 days of the date that your claim was received. (This claim review period may be extended for up to 45 additional days if the Insurance Company requires additional time to review your claim.) 

During the claim review period, the Insurance Company may require you to undergo a medical examination, at the Insurance Company’s expense. The Insurance Company will also notify you in writing of any additional information it needs to make a decision on your claim. 

If your claim is denied, in whole or in part, you will receive a written notice from the Insurance Company within the claim review period. The Insurance Company’s written notice will include the following information: 

  1. The specific reason(s) the claim was denied.
  2. Specific reference to the Policy provision(s) on which the denial was based.
  3. Any additional information required for your claim to be reconsidered, and the reason this information is necessary.
  4. In the case of any claim for a disability benefit, identification of any internal rule, guideline or protocol relied on in making the claim decision, and an explanation of any medically-related exclusion or limitation involved in the decision.
  5. A statement informing you of your right to appeal the decision, and an explanation of the appeal procedure, including a statement of your right to bring a civil action under Section 502(a) of ERISA if your appeal is denied.
  6. A statemetn that you are entitled to receive upon request, and without charge, reasonable access to or copies of all documents, records or other information relevant to the determination.
  7. A statement that you or your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency.

Whenever a claim is denied, you have the right to appeal the decision. You (or your duly authorized representative) must make a written request for appeal to the Insurance Company within 180 days from the date you receive the denial. If you do not make this request within that time, you will have waived your right to appeal.

Once your request has been received by the Insurance Company, a prompt and complete review of your claim must take place. This review will give no deference to the original claim decision, and will not be made by the person who made the initial claim decision. During the review, you (or your duly authorized representative) have the right to review any documents that have a bearing on the claim, including the documents which establish and control the Plan. Any medical or vocational experts consulted by the Insurance Company will be identified. You may also submit issues and comments that you feel might affect the outcome of the review.

The Insurance Company has 45 days from the date it receives your request to review your claim and notify you of its decision. Under special circumstances, the Insurance Company may require more time to review your claim. If this should happen, the Insurance Company must notify you, in writing, that its review period has been extended for an additional 45 days. Once its review is complete, the Insurance Company must notify you, in writing, of the results of the review and indicate the Plan provisions upon which it based its decision. 

LIFE INSURANCE AND AD&D CLAIM DENIAL AND APPEAL

The following claim denial and appeal procedures apply for:

  • Employee Basic Life Insurance
  • Optional Term Life Insurance
  • Dependent Life Insurance
  • Basic and Voluntary Accidental Death and Dismemberment (AD&D) Insurance 

Claim Denial
If your claim for Life Insurance or AD&D Insurance Plan benefits is denied (in whole or in part), you or your authorized representative will receive a written notice of the denial and the reasons for it. The denial notice will include: 

  1. The specific reason(s) the claim was denied.
  2. Specific reference to the Policy provision(s) on which the denial was based.
  3. Any additional information required for your claim to be reconsidered, and the reason this information is necessary.
  4. In the case of any claim for a disability benefit, identification of any internal rule, guideline or protocol relied on in making the claim decision, and an explanation of any medically-related exclusion or limitation involved in the decision.
  5. A statement informing you of your right to appeal the decision, and an explanation of the appeal procedure, including a statement of your right to bring a civil action under Section 502(a) of ERISA if your appeal is denied. 

Appeal Procedure for Denied Claims
You can appeal a denied claim. A written request for appeal must be made to the Claim Administrator within 90 days (180 days in the case of any claim for disability benefits) from the date the denial was received. If a request is not made within that time, the right to appeal will have been waived. 

Once a request has been received by the Claim Administrator, a prompt and complete review of the claim will take place. This review will give no deference to the original claim decision. It will not be made by the person who made the initial claim decision, or a subordinate of that person. During the review, the claimant (or the claimant’s duly authorized representative) has the right to review any documents that have a bearing on the claim, including the documents which establish and control the Plan. Any medical or vocational experts consulted by the Claim Administrator will be identified. Issues and comments that might affect the outcome of the review may also be submitted. 

The Claim Administrator has 60 days (45 days, in the case of any disability benefit) from the date it receives a request to review the claim and provide its decision. Under special circumstances, the Claim Administrator may require more time to review the claim. If this should happen, the Claim Administrator must provide notice, in writing, that its review period has been extended for an additional 60 days (45 days in the case of any disability benefit). Once its review is complete, the Claim Administrator must state, in writing, the results of the review and indicate the Plan provisions upon which it based its decision. 

LONG-TERM CARE INSURANCE PLAN CLAIM DENIAL AND APPEAL
(Applies only to employees enrolled in the plan prior to 12/31/2011)

If your claim for Long-Term Care Insurance Plan benefits is denied (in whole or in part), you or your authorized representative will receive a written notice of the denial and the reasons for it. You will then be entitled to a review of the denial if: 

  • you make a written request for this review; and
  • you send your request for review to the Claim Administrator within 60 days of the date that you received the denial.

The Claim Administrator will make its decision regarding your request for claim reconsideration within 60 days after the date that it receives your request. If you still disagree with the Claim Administrator’s decision, you can appeal that decision by following the steps outlined below. 

Claim Appeal
You can appeal a denied claim. Your appeal request should be in writing, and state the following: 

  • the reasons why you disagree with the Claim Administrator’s determination;
  • what additional factors (if any) that the Claim Administrator should take into consideration; and
  • the names, addresses, and phone numbers of any person or organization that the Claim Administrator should contact to obtain any additional pertinent information regarding your condition or care.

The Claim Administrator will make a full and fair review of your claim. The Claim Administrator may require additional information to objectively evaluate your appeal, and may (at the Claim Administrator’s expense) use one or more of the following resources: 

  • a physician who will assess your condition and report it to the Claim Administrator;
  • an on-site geriatric assessment; or
  • medical records from your physician(s) and/or provider(s) of care. 

Final Decision
The Claim Administrator will make a final decision with respect to your claim appeal. This decision will be in writing, and usually sent to you within 60 days after the date that the Claim Administrator receives your appeal request. If your appeal is denied, the Claim Administrator’s written decision will include the specific reasons for the denial. 

FLEXIBLE SPENDING ACCOUNT PLAN CLAIM DENIAL AND APPEAL

If you are denied a benefit under the Flexible Spending Account Health Care or Dependent Care Plans, you should proceed in accordance with the following claims review procedures:

(a)  if your claim is denied, you will receive written notice from the Claim Administrator that your claim was denied as soon as reasonably possible, but no later than 30 days after receipt of the claim. For reasons beyond the control of the Claim Administrator, the Claim Administrator may take up to an additional 15 days to review your claim. You will be provided written notice of the need for additional time prior to the end of the 30-day period. If the reason for the additional time is that you need to provide additional information, you will have 45 days from the notice of the extension to obtain that information. The time period during which the Claim Administrator must make a decision will be suspended until the earlier of the date that you provide the information or the end of the 45-day period;

(b)  once you have received your notice from the Claim Administrator, review it carefully. The notice will contain:

    • the reason(s) for the denial and the plan provisions on which the denial is based;
    • a description of any additional information necessary for you to perfect your claim, why the information is necessary, and your time limit for submitting the information;
    • a description of the plan’s appeal procedures and the time limits applicable to such procedures; and
    • a right to request all documentation relevant to your claim.

APPEALING A DENIED CLAIM 

(c)  if you disagree with the decision of the Claim Administrator, you or your legal representative may file a written appeal. You or your legal representative should file your appeal with the Claim Administrator no later than 180 days after receipt of the notice described in paragraph (a). You or your legal representative should submit all information identified in the notice of denial as necessary to perfect your claim and any additional information that you believe would support your claim;

(d)  if you receive a Notice of Denial from the claims reviewer and the claim is again denied, you will be notified in writing no later than 30 days after receipt of the appeal by the Claim Administrator;

(e)  review your notice carefully. You or your legal representative should take the same action that you take in paragraph (b) described above. The notice will contain the same type of information that is provided in the first notice of denial provided by the Claim Administrator; and

(f)  if you still disagree with the Claim Administrator’s decision, you or your legal representative should file a 2nd Level Appeal with the Plan Administrator. If you still do not agree with the Claim Administrator’s decision, you may file a written appeal with the Plan Administrator within 60 days after receiving the first level appeal denial notice from the Claim Administrator. You should gather any additional information that is identified in the notice as necessary to perfect your claim and any other information that you believe would support your claim.

If the Plan Administrator denies your 2nd Level Appeal, you will receive notice within 30 days after the Plan Administrator receives your claim. The notice will contain the same type of information that was referenced in paragraph (a) above.

Other important information regarding your appeals: 

  • each level of appeal will be independent from the previous level (i.e., the same person(s) or subordinates of the same person(s) involved in a prior level of appeal would not be involved in the appeal);
  • on each level of appeal, the claims reviewer will review relevant information that you submit even if it is new information;
  • the Plan Administrator is required to give you or your legal representative notice of any internal rules, guidelines, protocols or similar criteria used as a basis for the adverse determination;
  • you cannot file suit in federal court until you have exhausted these appeals procedures, however, you have the right to file suit under ERISA Section 502 following an adverse appeal decision; and
  • each Participant has the right to request and obtain documents, records and other information as it pertains to their Benefit Plan(s). 

GROUP LEGAL PLAN CLAIM DENIAL AND APPEAL

If your claim is denied you have the right to have the denial reviewed. Your written appeal should state why you believe that your claim is valid and should be honored. You should mail or fax your appeal to:

Customer Advocate
ARAG
PO Box 9171
Des Moines, IA 50306-9171
Fax: 515-246-8710

If you are still not satisfied after receiving a written response from ARAG, you may enter into a formal grievance process or take advantage of a review process set up by ARAG. When you enter ARAG’s formal grievance process both parties agree to select an arbitrator who, in turn, agree on an independent third party arbitrator who will make a final decision that is binding on both parties. For a complete description of the formal grievance process see below. You also have the right to file a complaint with the State Bar about your attorney at any time.

Formal Grievance Process
If you disagree with denial of your claim under the plan, you have the right to appeal. If you choose to appeal you must file your appeal with ARAG in writing no later than 60 days after receipt of your denial. If you do not file your appeal within 60 days you will lose any right to further review of your claim. 

If you choose to request an appeal of your denial, please include your printed name and address, the claim number provided to you on the denial form and the date you are submitting the request. You may also submit written comments, documents, records, and other information relating to your claim regardless of whether this information was submitted with your initial claim for benefits. You may also request from ARAG reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits. These copies will be provided free of charge.

Send your request for appeal to: 

ARAG
Attention: Claims
PO Box 93180
Des Moines, IA 50309

ARAG will conduct a full and fair review of your claim and the denial of your claim. ARAG will take into account all comments, documents, records, and other information that you may submit related to your claim without regard to whether this information was submitted or considered in the initial determination of your claim.

ARAG will provide a written reply to your request for appeal and will notify you of its determination no later than 60 days after ARAG receives your request for review. If ARAG determines that an extension of time is required for processing your claim, ARAG will provide you with a written notice of the extension within 60 days after your request for review. Any extension may last no longer than 60 days after the termination of the initial 60-day period. 

EMPLOYEE ASSISTANCE PROGRAM

The Employee Assistance Program (EAP) does not have a formal claim or appeals procedure. If you have a question or concern about your EAP benefits, you should contact the Plan Administrator. While every effort will be made to address your question or concern, the Plan Administrator’s decision concerning your EAP benefits will be final, and not subject to appeal. 

ADOPTION ASSISTANCE PLAN

The Adoption Assistance Plan does not have a formal claim or appeals procedure. If you have a question or concern about your Adoption Assistance Plan benefits, you should contact the Plan Administrator. While every effort will be made to address your question or concern, the Plan Administrator’s decision concerning your Adoption Assistance Plan benefits will be final, and not subject to appeal.