McKesson 2005 Annual Report Download - page 202

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 change
upon request; and
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.
e. Right to Second Appeal. If on first review, the Insurance Company upholds the denial of a claimant’s claim for benefits, the claimant
(or the claimant’s authorized representative) may again appeal the denial by submitting a written request for a second review of the claim to the
Insurance Company within 60 days after receiving the written notice described in Section J.2.d.
A request for a second review shall set forth all of the grounds upon which it is based, all facts in support thereof, and any other matters that
the claimant deems pertinent. The procedures set forth in Section J.2.c. shall apply to the second review.
f. Decision on Second Review. The Insurance Company shall act upon each request for a second review within the time frames indicated
below.
i. For Urgent Care Claims, not later than 36 hours after receiving the second appeal.
ii. For Pre-Service Claims, not later than 15 days after receiving the second appeal.
iii. For Post-Service Claims, not later than 30 days after receiving the second appeal.
In the event that the Insurance Company determines on second 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 information specified in Section J.2.d.
3. Voluntary Appeal.
The Insurance Company provides for a voluntary level of appeal if a claimant’s claim for benefits has been denied following the required
second level of review. The procedure for the voluntary level of appeal is described in the Certificate of Coverage or Summary of Coverage
provided by the Insurance Company.
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