Original Claim Sample Clauses

Original Claim. ▇▇▇▇ ▇▇▇ or his surviving spouse may, if he or she so desires, file with the Board of Directors a written claim for benefits under the Agreement. Within ninety (90) days after the filing of such a claim, the Board of Directors shall notify the claimant in writing whether his claim is upheld or denied in whole or in part or shall furnish the claimant a written notice describing specific special circumstances requiring a specified amount of additional time (but not more than one hundred eighty days from the date the claim was filed) to reach a decision on the claim. If the claim is denied in whole or in part, the Board of Directors shall state in writing: (a) the specific reasons for the denial; (b) the specific references to the pertinent provisions of this Agreement on which the denial is based; (c) a description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary; and (d) an explanation of the claims review procedure set forth in this section.

Original Claim. Claims shall be submitted within one hundred eighty (180) days of the date of service or within one hundred eighty (180) days of the primary payer’s dated provider claims summary. Claims which are not submitted within the timely filing requirements herein will not be honored and Group agrees not to bill The Plan or Member for services associated with such claims.

Original Claim. Any employee, former employee, or Beneficiary of such employee or former employee may, if the employee, former employee or Beneficiary so desires, file with the Committee a written claim for benefits under the Plan. Within ninety (90) days -67- after the filing of such a claim, the Committee shall notify the claimant in writing whether the claim is upheld or denied in whole or in part or shall furnish the claimant a written notice describing specific special circumstances requiring a specified amount of additional time (but not more than one hundred eighty days from the date the claim was filed) to reach a decision on the claim. If the claim is denied in whole or in part, the Committee shall state in writing: THE SPECIFIC REASONS FOR THE DENIAL, THE SPECIFIC REFERENCES TO THE PERTINENT PROVISIONS OF THIS PLAN STATEMENT ON WHICH THE DENIAL IS BASED, A DESCRIPTION OF ANY ADDITIONAL MATERIAL OR INFORMATION NECESSARY FOR THE CLAIMANT TO PERFECT THE CLAIM AND AN EXPLANATION OF WHY SUCH MATERIAL OR INFORMATION IS NECESSARY, AND AN EXPLANATION OF THE CLAIMS REVIEW PROCEDURE SET FORTH IN THIS SECTION. CLAIMS REVIEW PROCEDURE. Within sixty (60) days after receipt of notice that the claim has been denied in whole or in part, the claimant may file with the Committee a written request for a review and may, in conjunction therewith, submit written issues and comments. Within sixty (60) days after the filing of such a request for review, the Committee shall notify the claimant in writing whether, upon review, the claim was upheld or denied in whole or in part or shall furnish the claimant a written notice describing specific special circumstances requiring a specified amount of additional time (but not more than one hundred twenty days from the date the request for review was filed) to reach a decision on the request for review. GENERAL RULES. NO INQUIRY OR QUESTION SHALL BE DEEMED TO BE A CLAIM OR A REQUEST FOR A REVIEW OF A DENIED CLAIM UNLESS MADE IN ACCORDANCE WITH THE CLAIMS PROCEDURE. THE COMMITTEE MAY REQUIRE THAT ANY CLAIM FOR BENEFITS AND ANY REQUEST FOR A REVIEW OF A DENIED CLAIM BE FILED ON FORMS TO BE FURNISHED BY THE COMMITTEE UPON REQUEST. ALL DECISIONS ON CLAIMS AND ON REQUESTS FOR A REVIEW OF DENIED CLAIMS SHALL BE MADE BY THE COMMITTEE UNLESS DELEGATED AS PROVIDED IN SECTION 12.2. THE COMMITTEE MAY, IN ITS DISCRETION, HOLD ONE OR MORE HEARINGS ON A CLAIM OR A REQUEST FOR A REVIEW OF A DENIED CLAIM. CLAIMANTS MAY BE REPRESENTED BY A LAWYER OR OTHER REPRE...

Original Claim. Any Employee, former Employee or Beneficiary of such Employee or former Employee may, if he so desires, file with the Administrator's Representative a written claim for benefits under this Plan. Within ninety (90) days after the filing of such a claim, the Administrator's Representative shall notify the claimant in writing whether his claim is upheld or denied in whole or in part or shall furnish the claimant a written notice describing specific special circumstances requiring a specified amount of additional time (but not more than one hundred eighty days from the date the claim was filed) to reach a decision on the claim. If the claim is denied in whole or in part, the Administrator's Representative shall state in writing: (a) the specific reasons for the denial, (b) the specific references to the pertinent provisions of the Plan Statement on which the denial is based, (c) a description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary, and (d) an explanation of the claims review procedure set forth in this section.