TIME PERIODS FOR MAKING DECISIONS ON APPEALS After reviewing a claim that has been appealed, the Plan will notify the Covered Person of its decision within the following timeframes, although Covered Persons may voluntarily extend these timelines. In addition, if any new or additional evidence is relied upon or generated during the determination of the appeal, the Plan will provide such evidence to You free of charge and sufficiently in advance of the due date of the response to the Adverse Benefit Determination. If such evidence is received at a point in the process where the Plan is unable to provide You with a reasonable opportunity to respond prior to the end of the period stated below, the time period will be tolled to allow You a reasonable opportunity to respond to the new or additional evidence. The timelines below will apply only to the mandatory appeal level. The voluntary appeal level will not be subject to specific timelines. • Pre-Service Claims: Within a reasonable period of time appropriate to the medical circumstances, but no later than 30 calendar days after the Plan receives the request for review. • Post-Service Claims: Within a reasonable period of time, but no later than 60 calendar days after the Plan receives the request for review. • Concurrent Care Claims: Before treatment ends or is reduced. RIGHT TO EXTERNAL REVIEW If, after exhausting Your internal appeals, You are not satisfied with the final determination, You may choose to participate in the external review program. This program applies only if the Adverse Benefit Determination involves: • Clinical reasons; • The exclusions for Experimental, Investigational, or Unproven services; • Determinations related to Your entitlement to a reasonable alternative standard for a reward under a Wellness Program; • Determinations related to whether the Plan has complied with non-quantitative treatment limitation provisions of Code 9812 or 54.9812 (Parity in Mental Health and Substance Use Disorder Benefits); • Determinations related to the Plan’s compliance with the following surprise billing and cost-sharing protections set forth in the No Surprises Act: ➢ Whether a claim is for Emergency treatment that involves medical judgment or consideration of compliance with the cost-sharing and surprise billing protections; ➢ Whether a claim for items and services was furnished by a non-network provider at a network facility; ➢ Whether an individual gave informed consent to waive the protections under the No Surprises Act; ➢ Whether a claim for items and services is coded correctly and is consistent with the treatment actually received; ➢ Whether cost-sharing was appropriately calculated for claims for Ancillary Services provided by a non-network provider at a network facility; or • Other requirements of applicable law. This external review program offers an independent review process to review the denial of a requested service or procedure (other than a pre-determination of benefits) or the denial of payment for a service or procedure. The process is available at no charge to You after You have exhausted the appeals process identified above and You receive a decision that is unfavorable, or if UMR or Your employer fails to respond to Your appeal within the timelines stated above. -104- 7670-00-413597