127 Federal Notice Pre-Service Request for Benefits* Type of Request for Benefits or Appeal Timing You must appeal the first level appeal (file a second level appeal) within: 60 days after receiving the first level appeal decision The Claims Fiduciary must notify you of the second level appeal decision within: 15 days after receiving the second level appeal *The Claims Administrator may require a one-time extension for the initial claim determination, of no more than 15 days, only if more time is needed due to circumstances beyond control of the Plan. Urgent Requests for Benefits that Require Immediate Attention Urgent requests for Benefits are those that require notification or a benefit determination prior to receiving medical care, where a delay in treatment could seriously jeopardize your life or health, or the ability to regain maximum function or, in the opinion of a Physician with knowledge of your medical condition, could cause severe pain. In these situations, you will receive notice of the benefit determination in writing or electronically within 72 hours after the Claims Administrator receives all necessary information, taking into account the seriousness of your condition. If you filed an urgent request for Benefits improperly, the Claims Administrator will notify you of the improper filing and how to correct it within 24 hours after the urgent request was received. If additional information is needed to process the request, the Claims Administrator will notify you of the information needed within 24 hours after the request was received. You then have 48 hours to provide the requested information. You will be notified of a benefit determination no later than 48 hours after: • The Claims Administrator's receipt of the requested information. • The end of the 48-hour period within which you were to provide the additional information, if the information is not received within that time. A denial notice will explain the reason for denial, refer to the part of the plan on which the denial is based, and provide the claim appeal procedures. Urgent Care Request for Benefits* Type of Request for Benefits or Appeal Timing If your request for Benefits is incomplete, the Claims Administrator must notify you within: 24 hours You must then provide completed request for Benefits to the Claims Administrator within: 48 hours after receiving notice of additional information required The Claims Administrator must notify you of the benefit determination within: 72 hours If the Claims Administrator denies your request for Benefits, you must appeal an adverse benefit determination no later than: 180 days after receiving the adverse benefit determination The Claims Administrator must notify you of the appeal decision within: 72 hours after receiving the appeal *You do not need to submit urgent care appeals in writing. You should call the Claims Administrator as soon as possible to appeal an urgent care request for Benefits.