• Termination of the group health Plan. • The Employee, Dependent, or provider did not respond to a request for additional information needed to process the claim or appeal. • Application of Coordination of Benefits. • Enforcement of subrogation. • Services are not a covered benefit under this Plan. • Services are not considered Medically Necessary. • Failure to comply with prior authorization requirements before receiving services. • Misuse of the Plan identification card or other fraud. • Failure to pay premiums if required. • The Employee or Dependent is responsible for charges due to Deductible, Plan Participation obligations, or penalties. • Application of the Protection from Balance Billing allowed amount, the Usual and Customary fee limits, the fee schedule, or Negotiated Rates. • Incomplete or inaccurate claim submission. • Application of utilization review. • Procedures are considered Experimental, Investigational or Unproven. • Other reasons as stated elsewhere in this SPD. ADVERSE BENEFIT DETERMINATION (DENIED CLAIMS) Adverse Benefit Determination means a denial, reduction, or termination of a benefit, or a failure to provide or make payment, in whole or in part, for a benefit. It also includes any such denial, reduction, termination, rescission of coverage (whether or not, in connection with the rescission, there is an adverse effect on any particular benefit at that time), or failure to provide or make payment that is based on a determination that the Covered Person is no longer eligible to participate in the Plan. If a claim is being denied, in whole or in part, and the Covered Person will owe any amount to the provider, the Covered Person will receive an initial claim denial notice, usually referred to as an Explanation of Benefits (EOB) form, within the timelines described above. The EOB form will: • Explain the specific reasons for the denial. • Provide a specific reference to pertinent Plan provisions on which the denial was based. • Provide a description of any material or information that is necessary for the Covered Person to perfect the claim, along with an explanation of why such material or information is necessary, if applicable. • Provide appropriate information as to the steps the Covered Person may take to submit the claim for appeal (review). If an internal rule or guideline was relied upon, or if the denial was based on Medical Necessity or Experimental, Investigational, or Unproven treatment, the Plan will notify the Covered Person of that fact. The Covered Person has the right to request a copy of the rule/guideline or clinical criteria that were relied upon, and such information will be provided free of charge. APPEALS PROCEDURE FOR ADVERSE BENEFIT DETERMINATIONS If a Covered Person disagrees with the denial of a claim or a rescission of coverage determination, the Covered Person or his or her Personal Representative may request that the Plan review its initial determination by submitting a written request to the Plan as described below. An appeal filed by a provider on the Covered Person’s behalf is not considered an appeal under the Plan unless the provider is a Personal Representative. -101- 7670-00-413597