Common use of Formal Appeal Clause in Contracts

Formal Appeal. A Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information:  The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number;  The Insured’s SHL Membership number; and  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department ▇▇ ▇▇▇ ▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ SHL will investigate the appeal. When the investigation is complete, the Insured will be informed, in writing, of the resolution within thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one (1) time by SHL for up to fifteen

Formal Appeal. A Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information:  • The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number;  • The Insured’s SHL Membership numbernumber ; and  • A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department ▇▇ .▇. ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇ ▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇ Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ SHL will investigate the appeal. When the investigation is complete, the Insured will be informed, informed in writing, writing of the resolution within thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one one (1) time by SHL for up to fifteenfifteen (15) days, provided that the extension is necessary due to matters beyond the control of SHL and SHL notifies the Insured prior to the expiration of the initial thirty (30) day period of the circumstances requiring the extension and the date by which SHL expects to render a decision. If the extension is necessary due to a failure of the Insured to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information and the Insured shall be afforded at least forty- five (45) days from receipt of the notice to provide the information. If the Formal Appeal results in an Adverse Benefit Determination, the Insured will be informed in writing of the following: • The specific reason or reasons for upholding the Adverse Benefit Determination; • Reference to the specific Plan provisions on which the determination is based; • A statement that the Insured is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the Insured’s Claim for Benefits; • A statement that any internal rule, guideline, protocol or other similar criteria that was relied on in making the determination is available free of charge upon the Insured’s request; and • If the Adverse Benefit Determination is based on Medical Necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment or a statement that such explanation will be provided free of charge as well as information regarding the Insured’s right to request an External Review by the State of Nevada’s Office for Consumer Health Assistance (OCHA). Limited extensions may be required if additional information is required in order for SHL to reach a resolution.

Formal Appeal. A Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information:  The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number;  The Insured’s SHL Membership numbernumber ; and  A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department ▇▇ ▇▇▇ ▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ SHL will investigate the appeal. When the investigation is complete, the Insured will be informed, in writing, of the resolution within thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one (1) time by SHL for up to fifteen

Formal Appeal. A Formal Appeal must be submitted orally or in writing to SHL’s Customer Response and Resolution Department within 180 days of an Adverse Benefit Determination. Formal Appeals not filed in a timely manner will be deemed waived with respect to the Adverse Benefit Determination to which they relate. A Formal Appeal shall contain at least the following information:  • The Insured’s name (or name of Insured and Insured’s Authorized Representative), address, and telephone number;  • The Insured’s SHL Membership numbernumber ; and  • A brief statement of the nature of the matter, the reason(s) for the appeal, and why the Insured feels that the Adverse Benefit Determination was wrong. Additionally, the Insured may submit any supporting medical records, Physician’s letters, or other information that explains why SHL should approve the Claim for Benefits. The Insured can request the assistance of a Member Services Representative at any time during this process. The Formal Appeals should be sent or faxed to the following: Sierra Health and Life Insurance Co., Inc. Attn: Customer Response and Resolution Department ▇▇ ▇▇▇ ▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇ Fax: ▇-▇▇▇-▇▇▇-▇▇▇▇ SHL will investigate the appeal. When the investigation is complete, the Insured will be informed, informed in writing, writing of the resolution within thirty (30) days of receipt of the request for the Formal Appeal. This period may be extended one (1) time by SHL for up to fifteenthirty