SSMC Employee Health Benefit Plan
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3. Claimant Appeals of Adverse Benefit Determinations. According to the regulations, a Claimant
must be provided a reasonable opportunity to appeal an Adverse Benefit Determination. The Plan
appeal procedures must provide for a full and fair review of the Claim and the Adverse Benefit
Determination.
a. Claimant Time Line for Appeal. If a Claim for Benefits is denied in, whole or in part, or if the
applicant had no response to such Claim within the timelines shown above for type of Claim (in
which case the Claim for Benefits will be deemed to have been denied), the claimant may appeal
the denial to the Claims Administrator. All Claim appeals must be submitted within 180 days
after the date the Claim is deemed denied. Note: Failure to send a written appeal within 180 days
from the date such Claim is deemed to be denied could result in continued denial without further
Claim review by the Plan Administrator or Claims Administrator
b. For Pre-Service Urgent Care. To obtain full and fair review, the Claimant or his/her authorized
representative may submit a request for an expedited appeal of an Adverse Benefit Determination
orally or in writing. All necessary information, including the Plan benefit determination on
review, shall be transmitted between the Plan and the Claimant by telephone, facsimile, or other
available similarly expeditious method.
c. All other Adverse Benefit Determinations. To obtain a full and fair review, the Claimant or
his/her authorized representative must send a written appeal of an Adverse Benefit Determination
within 180 days after the date the Claim is deemed denied. The written appeal should include
written comments, documents, and other information that support the appeal. The written request
should be sent to the Claims Administrator: POMCO; Sound Shore Medical Center Claim
Appeals; P.O. Box 6329; Syracuse, NY 13217-6329.
d. Full and Fair Review. To comply with the federal regulations concerning Full and Fair Review
procedures, the Plan will provide the Claimant or the Claimant's authorized representative:
·
The opportunity to submit written comments, documents, records, and other information
relating to the Claim for Benefits.
·
Upon request and free of charge, reasonable access to, and copies of, all documents,
records, and other information Relevant to the Claim for Benefits.
·
A review that takes into account all comments, documents, records, and other information
submitted by the Claimant relating to the Claim for Benefits, without regard to whether
such information was submitted or considered in the initial benefit determination.
·
A review that does not afford deference to the initial Adverse Benefit Determination and
that is conducted by an appropriate named fiduciary of the Plan who is neither the
individual who made the Adverse Benefit Determination that is the subject of the appeal,
nor the subordinate of such individual;
·
That, in deciding an appeal of any Adverse Benefit Determination 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, Investigative, 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;
·
The identification of medical or vocational experts whose advice was obtained on behalf of
the Plan in connection with a Claimant's Adverse Benefit Determination, without regard to
whether the advice was relied upon in making the benefit determination;
