Welfare Summary Plan Description

6.5 REQUEST FOR REVIEW OF DENIAL OF BENEFITS BASED ON PRECERTIFICATION REVIEW

Regular Request for Review
If the Utilization Management Organization determines that the proposed service is not Medically Necessary, you and/or your Physician may submit a written request for review accompanied by any additional information to support the need for the proposed service. The request for review should be sent to the Utilization Management Organization. You can expect that the Utilization Management Organization will respond in writing within 30 days after receiving the request and any required medical records and/or information.

Expedited Request for Review
If the Utilization Management Organization determines that the proposed service is not Medically Necessary, the treating Physician may telephone the Utilization Management Organization to request an expedited review with the medical director or a Physician designated by the Utilization Management Organization to provide the necessary review. The Utilization Management Organization will usually respond to your Physician by telephone within 24 working hours, and later confirm the determination in writing to you, your Physician, and the Administrative Office.

Independent Review of a Denial of Precertification
If the Utilization Management Organization confirms the initial determination that the proposed service is not Medically Necessary, you and/or your Physician may submit a written request for an independent medical review of the denial of precertification. Call the Trust Customer Service Office for information regarding this independent review. The independent medical reviewer will consider all information presented by your Physician and the Utilization Management Organization. You can expect a written response regarding this review from the Trust within 60 days after your request for such a review is received.

This independent medical review is not required and you may request review by the Administrative Committee at any time within 180 days after a denial of precertification, whether or not you may have requested an independent medical review.