CLAIMS AND APPEAL PROCEDURES REASONABLE AND CONSISTENT CLAIMS PROCEDURES The Plan’s claims procedures are designed to ensure and verify that claim determinations are made in accordance with the Plan documents. The Plan provisions will be applied consistently with respect to similarly situated individuals. Pre-Determination A Pre-Determination is a determination of benefits by the Claims Administrator, on behalf of the Plan, prior to services being provided. Although Pre-Determinations are not required by the Plan, a Covered Person or provider may voluntarily request a Pre-Determination. A Pre-Determination informs individuals of whether, and under which circumstances, a procedure or service is generally a covered benefit under the Plan. A Covered Person or provider may wish to request a Pre-Determination before Incurring medical expenses. A Pre-Determination is not a claim and therefore may not be appealed. A Pre- Determination that a procedure or service may be covered under the Plan does not guarantee the Plan will ultimately pay the claim. All Plan terms and conditions will still be applied when determining whether a claim is payable under the Plan. TYPE OF CLAIMS AND DEFINITIONS • Pre-Service Claim needing prior authorization as required by the Plan and stated in this SPD. This is a claim for a benefit where the Covered Person or provider, when applicable, is required to obtain approval from the Plan before obtaining medical care, such as in the case of prior authorization of health care items or services that the Plan requires. If a Covered Person or provider calls the Plan for the sole purpose of learning whether or not a claim will be covered, that call is not considered a Pre-Service Claim, unless the Plan and this SPD specifically require the person to call for prior authorization. (See “Pre-Determination” above.) The fact that the Plan may grant prior authorization does not guarantee that the Plan will ultimately pay the claim. Note that this Plan does not require prior authorization for urgent or Emergency care claims; however, Covered Persons may be required to notify the Plan following stabilization. Please refer to the UMR CARE section of this SPD for more details. A condition is considered to be an urgent or Emergency care situation if a sudden and serious condition occurs such that a Prudent Layperson could expect the patient’s life would be jeopardized, the patient would suffer severe pain, or serious impairment of the patient’s bodily functions would result unless immediate medical care is rendered. Examples of an urgent or Emergency care situation may include, but are not limited to: chest pain; hemorrhaging; syncope; fever equal to or greater than 103° F; presence of a foreign body in the throat, eye, or internal cavity; or a severe allergic reaction. • Post-Service Claim means a claim that involves payment for the cost of health care that has already been provided. • Concurrent Care Claim means that an ongoing course of treatment to be provided over a period of time or for a specified number of treatments has been approved by the Plan. PERSONAL REPRESENTATIVE Personal Representative means a person (or provider) who may contact the Plan on the Covered Person's behalf to help with claims, appeals or other benefit issues. A minor Dependent must have the signature of a parent or Legal Guardian in order to appoint a third party as a Personal Representative. -97- 7670-00-413597