McKesson 2005 Annual Report Download - page 201

who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of that individual; and
v. In deciding an appeal that is based in whole or in part on a medical judgment, including determinations with regard to whether a
particular treatment, drug or other item is experimental, investigational, or not medically necessary or appropriate, the appropriate named
fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the
medical judgment, and such health care professional shall not be the individual who was consulted in connection with the adverse benefit
determination that is the subject of the appeal (nor the subordinate of such individual); and
vi. The Insurance Company shall, upon request, provide for the identification of any medical or vocational experts whose advice was
obtained on behalf of the Plan in connection with the claimant’s adverse benefit determination, without regard to whether the advice was relied
upon in making the benefit determination.
d. Decision on First Review. The Insurance Company shall act upon each request for a first review within the time frames indicated in
the chart below.
In the event that the Insurance Company determines on first review that benefits are payable under the Plan, the Insurance Company will
process payment of the claim in accordance with the provisions of Section L.1. In the event that the Insurance Company confirms the denial of
the claim, in whole or in part, the Insurance Company shall notify the claimant of such denial in writing. 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 statement that the claimant is entitled to receive, 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; and
iv. A statement describing any voluntary appeal procedures offered by the Plan and the claimant’s right to obtain the information
about such procedures, and a statement of the claimant’s right to bring an action under Section 502(a) of ERISA following the completion of
all levels of appeal required by the Plan; and
22
Urgent Care Claim Pre-Service Claim Post-Service Claim
Not later than 36 hours after receiving the
appeal
Not later than 15 days after receiving the
appeal
Not later than 30 days after receiving the
appeal.