The person who reviews and decides an appeal will be a different individual than the person who initially processed the claim. The review will take into account all information submitted by the participant, whether or not presented or available when the claim was processed. No deference will be given to the initial benefit decision.
In the case of a claim denied on the grounds of a medical judgment, the Plan will consult with a health care professional with appropriate training and experience. The health care professional who is consulted on appeal will not be the same individual who was consulted, if any, regarding the initial benefit decision or a subordinate of that individual. Upon request and at no cost, a participant will be given reasonable access to and copies of all documents, records, and other information relevant to the claim for benefits. If advice of a medical or vocational expert was obtained in connection with the initial benefit decision, the names of each expert will be provided on request to the participant, regardless of whether the advice was relied on by the Plan.
The Plan will decide the outcome of an appeal of a pre-service claim within a reasonable time appropriate to the medical circumstances, but no later than 30 days after receipt by the Plan of the appeal request or 15 days if there are two levels of internal appeals. The Plan will decide the appeal of an urgent care claim as soon as possible, taking into account the medical emergency, but no later than 72 hours after receipt by the Plan of the appeal request. The Plan will decide the outcome of an appeal of a post-service claim within a reasonable period, but no later than 60 days of receipt by the Plan, or 30 days if there are two levels of internal appeals.