90 Your Right To Appeal We want your experience with us to be as positive as possible. There may be times, however, when you have a complaint, problem, or question about your Plan or a service you have received. In those cases, please contact Member Services by calling the numb er on the back of your ID card. We will try to resolve your complaint informally by talking to your Provider or reviewing your claim. If you are not satisfied with the resolution of your complaint, you have the right to file an appeal, which is defined a s follows: For purposes of these Appeal provisions, “claim for benefits” means a request for benefits under the Plan. The term includes both pre - service and post - service claims. • A pre - service claim is a claim for benefits under the plan for which you have not received the benefit or for which you may need to obtain approval in advance. • A post - service claim is any other claim for benefits under the plan for which you have received the service. If your claim is denied or if your coverage is rescinded: • you will be provided with a written notice of the denial or rescission; and • you are entitled to a full and fair review of the denial or rescission. The procedure we will follow will satisfy the requirements for a full and fair review under applicable federal regulations. Notice of Adverse Benefit Determination If your claim is denied, Our notice of the adverse benefit determination (denial) will include: • information sufficient to identify the claim involved; • the specific reason(s) for the denial; • a reference to the specific plan provision(s) on which the our determination is based; • a description of any additional material or information needed to perfect your claim; • an explanation of why the additional material or information is needed; • a description of the plan’s review procedures and the time limits that apply to them, including a statement of your right to bring a civil action under ERISA within one year of the grievance or appeals decision if you submit a grievance or appeal and the c laim denial is upheld; • information about any internal rule, guideline, protocol, or other similar criterion relied upon in making the claim determination and about your right to request a copy of it free of charge, along with a discussion of the claims denial decision; • information about the scientific or clinical judgment for any determination based on medical necessity or experimental treatment, or about your right to request this explanation free of charge, along with a discussion of the claims denial decision; and • Information regarding your potential right to an External Appeal pursuant to federal law. For claims involving urgent/concurrent care: • our notice will also include a description of the applicable urgent/concurrent review process; and • we may notify you or your authorized representative within 72 hours orally and then furnish a written notification. Appeals You have the right to appeal an adverse benefit determination (claim denial or rescission of coverage).