Your Claim Processing & Appeal Rights
[Self-Funded Group Health Plan]

Your self-funded Group Health Plan (Plan) coverage is provided through an employee welfare benefit plan established by your employer. As a Plan participant, you [and your covered dependent(s)] have certain claim processing and appeal rights under the Employee Retirement Income Security Act of 1974 (as amended) (ERISA).

1. Introduction

Notice: These procedures are furnished as a separate document that accompanies the Summary Plan Description (SPD) for your Plan. Consult the SPD for details regarding the benefits provided under the Plan.

Purpose: Under ERISA and applicable U.S. Department of Labor (DOL) regulations, claimants are entitled to full and fair review of any claims made under the Plan. This Notice is intended to comply with ERISA and DOL regulations by providing reasonable procedures governing the filing of benefit claims, the issuing of benefit decisions and the appeal of adverse benefit determinations.

2. Definitions

Plan: The Plan is the Employee Welfare Benefit Plan established by your employer.

Claim: A claim is any request for Plan benefits made in accordance with these procedures. Any communication regarding benefits that is not made in accordance with these procedures will not be treated as a claim under these procedures.

Claimant: You become a claimant when you make a request for Plan benefits in accordance with these procedures. Incorrectly-Filed Claim: Any request for benefits that is not made in accordance with these procedures is called an incorrectly-filed claim.

Authorized Representative: An authorized representative may act on behalf of a claimant with respect to a benefit claim or appeal under these procedures. However, no person (including a treating health care professional) will be recognized until the Plan receives written authorization signed by the claimant. Once an authorized representative is appointed, the Plan shall direct all information, notification, etc. regarding the claim to the authorized representative. The claimant shall be copied on all notifications regarding determinations, unless the claimant provides specific written direction otherwise. Any reference in these procedures to claimant is intended to include the authorized representative of such claimant appointed in compliance with the above procedures.

Plan Sponsor/Plan Administrator/Plan Fiduciary/Plan Trustee: Your employer is the Plan Sponsor, Plan Administrator, Plan Fiduciary and Plan Trustee for the Plan. The Plan is self-insured by your employer and benefits are funded by employer and employee contributions. The Plan is not insured by an insurance company and your employer is solely responsible for all benefit payments. Your employer, in its capacity as the Plan Administrator and in light of the purposes for which the Plan was established and is maintained, shall consider and render, in its sole discretion, appropriate eligibility, coverage and benefit determinations. In particular, your employer shall have full and sole discretionary authority to interpret all Plan documents and to make all interpretive and factual determinations as to whether any individual is entitled to receive any benefits under the terms of the Plan. Your employer is also responsible for making claim and appeal determinations.

Designated Administrator: Your employer has, by agreement, delegated certain non-fiduciary, ministerial administrative acts, duties and responsibilities of the Plan to Allied National, LLC, a licensed third-party administrator (Allied National). As the designated administrator, Allied National is authorized to process enrollments, bill and collect contributions, process claims payments, and perform other services, according to the terms of the agreement.

3. How to File a Claim for Benefits

General Filing Rules: A claim for benefits is made when a claimant (or authorized representative) submits written Notice and Proof of Loss as required in the SPD to: Allied National, LLC, Attn: Claims Department, PO Box 29186, Shawnee Mission, KS 66201; or fax at 913-945-4399.

A claim will be treated as received by the Plan: (a) on the date it is hand delivered to the above address; (b) on the date that it is deposited in the U.S. Mail for first-class delivery in a properly stamped envelope containing the above name and address (the postmark on any such envelope will be proof of date of mailing); (c) on the next business day immediately following the date it is faxed using the above fax number; or (d) on the next business day immediately following the date it is electronically submitted in compliance with HIPAA electronic transaction standards.

Notice of a claim shall be filed within 30 calendar days, and Proof of Loss of a claim shall be filed within 90 calendar days, following receipt of the medical service, treatment or product to which the claim relates. However, if it was not reasonably possible to file notice or proof within those time periods, notice must be filed within 90 calendar days, and Proof of Loss must be filed within six (6) months, following receipt of the medical service, treatment or product (except in the case of legal incapacity of the claimant).

How Incorrectly-Filed Claims Are Treated: These procedures do not apply to any request for benefits that is not made in accordance with these procedures.


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