McKesson 2005 Annual Report Download - page 199

after receipt of the claim, provided that the claim was made to the Insurance Company at least 24 hours prior to the expiration of the prescribed
period of time or number of treatments previously approved. If the claimant’s request for extended treatment is not made at least 24 hours prior
to the end of the prescribed period of time or number of treatments, the request will be treated as an Urgent Care Claim and decided according
to the timeframes described in the chart above.
If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and the claimant requests
to extend treatment in a non-urgent circumstance, the claimant’s request will be considered a new claim and decided according to the Post-
Service Claim or Pre-Service Claim time limits, whichever applies.
If the claimant’s Concurrent Care Claim is not an Urgent Care Claim, and there is a reduction or termination of the previously approved on-
going course of treatment provided over a period of time or number of treatments (other than by Plan amendment or termination) before the
end of the period of time or number of treatments, the claimant will be notified by the Insurance Company sufficiently in advance of the
reduction or termination to allow the claimant to appeal the denial and receive a determination on appeal before the reduction or termination of
the benefit. To appeal a denial of a Concurrent Care Claim, the claimant must follow the appeal procedures described in Section J.2.
d. Denial of Claims. In the event any claim for benefits is denied, in whole or in part, the Insurance Company shall notify the claimant of
such denial in writing within the time frames set forth in Section J.1.c.; provided, however, that the notice of denial for an Urgent Care Claim
may be provided orally and a written or electronic confirmation shall follow within three (3) days. Such written notice shall set forth, in a
manner calculated to be understood by the claimant, the following information:
i. The specific reason(s) for the denial; and
ii. Reference to the specific Plan provision(s) on which the denial is based; and
iii. A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why
such material or information is necessary; and
iv. A description of the Plan’s review procedures and the time limits applicable to such procedures, including a statement of the
claimant’s right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on second review; and
v. If an internal rule, guideline, protocol, or other similar criterion was relied upon in denying the claim, either the specific rule,
guideline, protocol, or other similar criterion, or a statement that such rule, guideline, protocol or other similar criterion was relied upon in
denying the claim, and that a copy of such rule, guideline, protocol, or other similar criterion will be provided to the claimant free of charge
upon request; and
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