McKesson 2005 Annual Report Download - page 200

vi. If the denial is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the
scientific or clinical judgment for the determination, applying the terms of the Plan to the claimant’s medical circumstances, or a statement that
such explanation will be provided to the claimant free of charge upon request.
2. Review of Denied Claims.
a. Named Fiduciary. The Insurance Company is the named fiduciary which has the discretionary authority to act with respect to any
appeal from a denial of benefits. The Company is the named fiduciary which has the discretionary authority to determine eligibility for benefits
and to construe the terms of the Plan.
b. Right to Appeal. The Insurance Company provides for a two-level appeal process. Any person whose claim for benefits is denied, in
whole or in part, or such person’s authorized representative, may appeal the denial by submitting a written request for a review of the claim to
the Insurance Company within one hundred eighty (180) days after receiving written notice of the denial from the Insurance Company. A
request for review shall set forth all of the grounds upon which it is based, all facts in support thereof, and any other matters which the claimant
deems pertinent. The claimant shall be solely responsible for submitting a written request for review of the claim and any other information or
evidence which the claimant intends the Insurance Company to consider in order to render a decision on review. A claimant requesting an
appeal of a denied Urgent Care Claim may initiate an expedited appeal by calling the Insurance Company at the toll-free number on the ID
card issued by the Insurance Company. The Insurance Company may require the claimant to submit such additional facts, documents or other
material as it may deem necessary or appropriate in making its review.
c. Procedures on Review. If the claimant (or the claimant’s authorized representative) requests a review of a denied claim, the following
procedures shall apply:
i. The claimant (or the claimant’s authorized representative) shall have the opportunity to submit written comments, documents,
records, and other information relating to the claim; and
ii. The claimant (or the claimant’s authorized representative) shall be provided, upon request and free of charge, reasonable access to,
and copies of, all documents, records, and other information Relevant to the claimant’s claim for benefits (other than legally or medically
privileged documents); and
iii. The review shall take into account all comments, documents, records, and other information submitted by the claimant relating to
the claim, without regard to whether such comments, documents, records, and other information were submitted or considered in the initial
benefit determination; and
iv. The review shall not afford deference to the initial claim denial and shall be conducted by an appropriate named fiduciary of the
Plan who is neither the individual
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