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| ADMINISTRATIVE INFORMATION |
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| Filing
a Claim |
ERISA provides certain rights and protections to participants under
certain benefit plans. This includes the right to have a claims administrator
respond to your claim within a specified timeframe and your right to
appeal denied claims. This section summarizes the claims and appeals
procedures. You will receive more information about the appeal process
if a claim is actually denied.
Initial Claims
If you have followed the appropriate claim submission procedures (as
described in the summary section applicable to each plan) and your request
is denied, it is the plan administrator’s duty to notify you within
a specified timeframe (see below) after receiving your claim. This notification
will indicate the specific reasons for the denial, including references
to plan provisions that apply, a request for any additional information
that may be necessary to process your claim and a description of the
claims appeal procedures. If the denial of a health care or disability
claim is based on medical necessity, experimental treatment, or other
similar exclusion or limit, the plan administrator will provide an explanation
of the scientific or clinical judgment used in making the decision,
or a statement that an explanation will be provided free of charge upon
request.
Following are the timeframes in which the plan administrator must respond
to your claim:
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For "urgent" health claims: As soon
as possible, but not more than 72 hours. (For urgent claims, your
appeal can be telephoned or faxed.)
An urgent claim is one that requires notification or pre-approval
before receiving medical care, where a delay in treatment could
seriously jeopardize your life or health or the ability to regain
maximum function or that, in the opinion of a physician with knowledge
of your medical condition, could cause severe pain that cannot be
managed without the requested treatment. (The determination of whether
a claim involves urgent care will be made by an individual acting
on behalf of the plan, applying the judgment of a "prudent
layperson" who possesses an average knowledge of health and
medicine. However, the claim will automatically be treated as urgent
care if a physician who knows your medical condition determines
that the claim involves urgent care.)
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For "pre-service" health claims: Within
15 days of your claim (within 30 days if the plan administrator
request an extension).
A pre-service claim is one that requires notification or pre-approval
before receiving care. For example, some plans require that you
obtain pre-approval before receiving non-urgent behavioral health
or hospital care.
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For "post-service" health claims, including Medical,
Dental Vision and Health Care FSA claims: Within 30 days
of your claim (within 45 days if the plan administrator requests
an extension).
A post-service claim is for payment of benefits after medical, dental
and vision care has been received. For example, a claim that is
submitted after you go to the doctor's office would be a post-service
claim.
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For "concurrent care" health claims: Within
24 hours of your claim, provided your request is made at least 24
hours before the end of approved treatment. Otherwise, the timeframe
for urgent, pre-service or post-service claims (whichever is relevant)
will apply.
A concurrent care claim is to extend an ongoing course of treatment
that was previously approved for a specific period of time or number
of treatments (e.g., if a hospital admission was initially approved
for three days, and your doctor requests that it be extended to
five days). Concurrent care claims also include claims where the
plan reduces or terminates coverage for previously approved treatments.
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For Long-term Disability claims: Within 45 days
(within 105 days if the plan administrator requests up to two 30-day
extensions).
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For Life and Accident Insurance and Dependent Care FSA
claims: Within 90 days (within 180 days if the plan administrator
requests an extension).
If an extension is necessary, you will be notified.
Appeals of Denied Claims
If your claim is denied, you may appeal and have your claim reviewed.
You have 180 days from the time you are notified of the denial to appeal
Medical, Dental, Vision, Health Care FSA and Long-term Disability claims
and 60 days to appeal Life and Accident Insurance and Dependent Care
FSA claims. Your request for an appeal must be made in writing to the
Corporate Benefits department and should include the reasons you think
the claim should not be denied. You may also submit any additional documentation
that you believe supports your claim, even it was not submitted with
your original claim. Besides having the right to appeal, you or your
authorized representative may request a hearing or examine any pertinent
plan documents related to your claim, at no cost to you.
The plan administrator must act on your appeal within a specified timeframe
of receiving it. The timeframe depends on the type of claim that you
are appealing:
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For "urgent" health appeals: As soon
as possible, but not more than 72 hours after your appeal.
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For "pre-service" health care appeals:
Within 30 days of your appeal.
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For "post-service" health care appeals, including
Medical, Dental, Vision and Health Care FSA claims: Within
60 days of your appeal.
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For Long-term Disability appeals: Within 45 days
of your appeal (within 90 days if the plan administrator requests
an extension).
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For Life and Accident Insurance and Dependent Care FSA
appeals: Within 60 days (within 120 days if the plan administrator
requests an extension).
If a health or disability claim involves a medical judgment, the plan
must consult with a health care professional who has appropriate training
and experience in the field of medicine involved in that judgment. The
health care professional can’t be the same person or a subordinate
of the person who was consulted on the initial decision. A medical judgment
includes whether a treatment, drug, or other item is experimental, investigational,
or not medically necessary or appropriate.
The final decision will be sent to you in writing with an explanation
of the reasons for the decision, including references to plan provisions
on which the decision is based and a statement that you are entitled
to receive, upon request and free of charge, reasonable access and copies
of all relevant documents.
If your claim is denied on appeal, you have the right to bring civil
action under ERISA if your appeal is denied.
 
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Summary Plan Description
The Valassis Benefits Handbook serves as the Summary Plan
Description for most benefits. A 2008 handbook will be issued soon.
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