126 Federal Notice Post-Service Claims Type of Claim 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: 30 days after receiving the second level appeal Pre-service Requests for Benefits Pre-service requests for Benefits are those requests that require notification or approval prior to receiving medical care. If you have a pre-service request for Benefits, and it was submitted properly with all needed information, the Claims Administrator will send you written notice of the decision from the Claims Administrator within 15 days of receipt of the request. If you filed a pre-service request for Benefits improperly, the Claims Administrator will notify you of the improper filing and how to correct it within five days after the pre-service request for Benefits was received. If additional information is needed to process the pre-service request, the Claims Administrator will notify you of the information needed within 15 days after it was received, and may request a one time extension not longer than 15 days and pend your request 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, the Claims Administrator will notify you of the determination within 15 days after the information is received. If you don't provide the needed information within the 45-day period, your request for Benefits 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 appeal procedures. If you have prescription drug Benefits and a retail or mail order pharmacy fails to fill a prescription that you have presented, you may file a pre-service health request for Benefits according to the applicable claim filing procedure. When you have filed a request for Benefits, your request will be treated under the same procedures for pre-service group health plan requests for Benefits as described in this section. Pre-Service Request for Benefits* Type of Request for Benefits or Appeal Timing If your request for Benefits is filed improperly, the Claims Administrator must notify you within: 5 days If your request for Benefits is incomplete, the Claims Administrator must notify you within: 15 days You must then provide completed request for Benefits information to the Claims Administrator within: 45 days The Claims Administrator must notify you of the benefit determination: • if the initial request for Benefits is complete, within: 15 days • after receiving the completed request for Benefits (if the initial request for Benefits is incomplete), within: 15 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: 15 days after receiving the first level appeal