125 Federal Notice Claims and Appeal Notice This Notice is provided to you in order to describe our responsibilities under Federal law for making benefit determinations and your right to appeal adverse benefit determinations. To the extent that state law provides you with more generous timelines or opportunities for appeal, those rights also apply to you. Please refer to your benefit documents for information about your rights under state law. Benefit Determinations Post-service Claims Post-service claims are those claims that are filed for payment of Benefits after medical care has been received. If your post-service claim is denied, you will receive a written notice from the Claims Administrator within 30 days of receipt of the claim, as long as all needed information was provided with the claim. The Claims Administrator will notify you within this 30 day period if additional information is needed to process the claim, and may request a one time extension not longer than 15 days and pend your claim until all information is received. Once notified of the extension, you then have 45 days to provide this information. If all of the needed information is received within the 45-day time frame, and the claim is denied, the Claims Administrator will notify you of the denial within 30 days after the information is received. If you don't provide the needed information within the 45-day period, your claim will be denied. 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. If you have prescription drug Benefits and are asked to pay the full cost of a prescription when you fill it at a retail or mail-order pharmacy, and if you believe that it should have been paid under the Plan, you may submit a claim for reimbursement according to the applicable claim filing procedures. If you pay a Copayment and believe that the amount of the Copayment was incorrect, you also may submit a claim for reimbursement according to the applicable claim filing procedures. When you have filed a claim, your claim will be treated under the same procedures for post-service group health plan claims as described in this section. Post-Service Claims Type of Claim or Appeal Timing If your claim is incomplete, the Claims Administrator must notify you within: 30 days You must then provide completed claim information to the Claims Administrator within: 45 days The Claims Administrator must notify you of the benefit determination: if the initial claim is complete, within: 30 days after receiving the completed claim (if the initial claim is incomplete), within: 30 days 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 first level appeal decision within: 30 days after receiving the first level appeal