12.4 Health Care Claim Denial The Plan Administrator will provide you with written notice of the denial of your claim. Such notice will include the following: (i) the specific reason(s) for your adverse benefit determination; (ii) reference to the specific Plan provision on which the determination is based; (iii) a description of any additional material or information necessary for you to fix your claim and an explanation of why such material or information is necessary; (iv) a description of the review procedures, including a statement of your right to bring a lawsuit following an adverse benefit determination on review; (v) either the specific rule or guideline used in making your benefits determination or a statement that such a rule or guideline was relied upon in making the determination and that a copy of such rule or guideline will be provided free of charge upon request; (vi) if the adverse benefit determination is based on a medical judgment, either an explanation of such judgment, or a statement that such explanation will be provided to you free of charge upon request; and (vii) in the case of an Urgent Care Claim, a description of the expedited review process to which you may be entitled. 12.5 Appealing A Denied Health Care Claim You have 180 days after the receipt of the denial notice to request a review of the denial. Your request for a review must be in writing unless your claim involves urgent care, in which case the request may be made orally. If you disagree with a claim determination, you can contact the Plan Administrator in writing to formally request an appeal. If the appeal relates to a claim for payment, your request should include: The patient's name and the identification number from the ID card, if any. The date(s) of health care service(s). The provider's name. The reason you believe the claim should be paid. Any documentation or other written information to support your request for claim payment. A qualified individual who was not involved in the decision being appealed will be appointed to decide the appeal. If your appeal is related to clinical matters, the review will be done in consultation with a health care professional with appropriate expertise in the field who was not involved in the prior determination. The Plan Administrator may consult with, or seek the participation of, medical experts as part of the appeal resolution process. You consent to this referral and the sharing of pertinent health claim information. Upon request and free of charge you have the right to reasonable access to and copies of, all documents, records, and other information relevant to your claim for benefits. Appeal Determination Notice Pre-Service and Post-Service Claim Appeals You will be provided with written or electronic notification of the decision on your appeal as follows: For appeals of Pre-Service Claims, the first level appeal will be conducted and you will be notified by the Plan Administrator of the decision within 15 days from receipt of a request for appeal of a denied claim. The second level appeal will be conducted and you will be notified by the Plan Administrator of the decision within 15 days from receipt of a request for review of the first level appeal decision. For appeals of Post-Service Claims, the first level appeal will be conducted and you will be notified by the Plan Administrator of the decision within 30 days from receipt of a request for appeal of a denied claim. The second level appeal will be conducted and you will be notified by the Plan Administrator of the decision within 30 days from receipt of a request for review of the first level appeal decision. Page 20