8. CLAIM PROVISIONS What if your claim is denied on review? If we deny all or any part of your claim on review, you will receive a Written notice of denial stating: · the specific reasons for the denial; · the specific Policy provisions and reasons on which the denial is based; · your right to appeal the decision and information regarding the department or person to contact for information about the decision and your right to appeal; · your right to receive, upon request and free of charge, copies of all documents, records, and other information relevant to your claim for benefits; · your right to bring a civil action under ERISA, §502(a), if applicable; and · the following statement: “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.” What is the procedure to file a grievance? A grievance or complaint is an expression of dissatisfaction regarding the handling or payment of claims, matters pertaining to the contractual relationship between you and us, or our decision to rescind this Certificate. You or your designee may submit a grievance verbally or in writing. Upon receipt of the grievance, the following steps will be taken: · We will acknowledge the grievance within 5 business days upon receipt. We will document the substance of the grievance and any actions taken. We will investigate the substance of the grievance, and after acquiring all information reasonably necessary to complete the review, we will make a decision regarding the grievance within 20 business days. If we are unable to make a decision regarding the grievance within the 20 business day period due to circumstances beyond our control, we will notify you in writing of the reason for the delay and issue a written decision regarding the grievance within an additional 10 business days. We will notify you in writing within 5 business days of reaching a resolution of the grievance. In that notice, we will: · provide a statement of the decision reached by us; · provide a statement of the reasons, policies, and procedures that are the basis of the decision; · provide you with notice of your right to appeal the decision; · provide you with the department, address, and telephone number where to contact a qualified representative to obtain additional information. Should you not agree with the decision, you have a right to appeal the grievance resolution. The appeal process is as follows: · We will issue a written or oral acknowledgment of the appeal no more than 5 business days after the appeal is filed. We will document the substance of the appeal and any actions taken. We will investigate the substance of the appeal and a decision will be made within 45 days after the filing of the appeal. We will notify you in writing within 5 business days of reaching a resolution of the appeal. In that notice, we will: · provide a statement of the disposition of the appeal; · provide a statement of the reasons, policies, and procedures that are the basis of the decision; · provide you with notice of the right to further remedies allowed by law, including the right to initiate an external grievance review by an independent review organization; · provide you with the department, address, and telephone number where to contact a qualified representative to obtain additional information. In situations where you do not agree with the decision of the appeal, you may have the right to further remedies allowed by the law, including the right to an external grievance review by an independent review organization. You will have no more than 120 days after you are notified of the appeal resolution to file a 16-AC-C-01 Page33