Processing of Claims, Appeals Sample Clauses

Processing of Claims, Appeals. Security Benefit will develop and distribute forms and establish procedures for submission of reimbursement claims by eligible participants to Security Benefit under the Program. All claims must be accompanied by proof deemed adequate by Security Benefit under the Cafeteria Plan Requirements to substantiate the amount, nature, and other necessary details of the expense for which the Participant claims reimbursement. If adequate proof of a claim is not provided, or the claim does not meet established guidelines for reimbursable claims, Security Benefit may, at its option, hold the claim pending receipt of adequate or acceptable proof, notify the Participant of a claim denial, or return the claim to the Participant for resubmission with adequate and acceptable proof. Security Benefit will establish further formal claim review and appeal procedures; provided, however, that the Employer will have the right to review such procedures and will remain responsible for adjudication of any appeal of an adverse benefit determination made with respect to an initial claim, in accordance with Section 3.4 of this Agreement. The Employer will also remain solely responsible for determining the individuals who are eligible to participate in the Plan and providing accurate information to Security Benefit regarding eligible Plan participants and dependents. In the event that an individual disputes the Employer’s determination regarding his eligibility to participate in the Plan, the Employer will be responsible for adjudicating any related claim and/or appeal.