This Benefits Handbook describes the claims review and appeal procedures for the following IQVIA Health Care Plans: Aetna $400 Deductible PPO Plan, Aetna $900 Deductible PPO Plan, Aetna $1,850 Deductible Plan, Aetna $2,850 Deductible Plan, Delta Dental Standard Plan, Delta Dental Enhanced Plan, and the EyeMed Vision Plan. If you have a claim or questions regarding a claim, contact the claim administrator for additional information. If you participate in any other IQVIA Health Care Plan, you should consult the information provided to you by these plans to determine the applicable claims review and appeal procedures.

Either you or your authorized representative may file claims for benefits under the IQVIA Health Care Plans. An "authorized representative" means a person you authorize, in writing, to act on your behalf. The plans also will recognize a court order giving a person the authority to submit claims on your behalf. All communications from the plans will be directed to your authorized representative unless your written designation provides otherwise.

In general, health services and benefits must be medically necessary to be covered under the medical and dental plans. The procedures for determining medical necessity vary according to the type of service or benefit requested and the type of health plan. Medical necessity determinations are made on either a pre-service, concurrent or post-service basis.

Certain services require prior authorization in order to be covered. This prior authorization is called a "pre-service medical necessity determination." This section describes who is responsible for obtaining this review. You or your authorized representative (typically, your health care provider) must request medical necessity determinations according to the procedures described in this section, and in your provider's network participation documents as applicable.

When services or benefits are determined to be not medically necessary, you or your representative will receive a written description of the adverse determination and may appeal the determination. Appeal procedures are described in this section, in your provider's network participation documents and in the determination notices.

Pre-service claims are for benefits that must be approved before receiving medical care, for example, requests to pre-certify a hospital stay or to obtain pre-approval under a utilization review program or for which a lesser coverage is provided in the absence of such approval.

For pre-service health claims, the claims administrator will notify you of the determination, whether adverse or not, within a reasonable period of time appropriate to the medical circumstances, but no later than 15 days after receipt of the claim. This period may be extended by 15 days if the claims administrator:

If the determination periods above would seriously jeopardize the life or health of the patient or the ability of the patient to regain maximum function or, in the judgment of a physician, would subject the patient to severe pain that could not be adequately managed without the care or treatment that is the subject of the claim, the claims administrator will expedite the pre-service determination.

For expedited claims, the claims administrator will notify you of the determination, whether adverse or not, as soon as possible considering the medical exigencies, but no later than 72 hours after receipt of the claim. If you fail to provide sufficient information for the claims administrator to determine whether, or to what extent, benefits are covered or payable under the plan, the claims administrator will notify you as soon as possible of the specific information necessary to complete the claim, but not later than 24 hours after the claims administrator receives the claim. You'll be given a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information.

The claims administrator will notify you of its benefit determination as soon as possible, but no later than 48 hours after the plan's receipt of the specified information or the end of the period you were given to provide the specified additional information, whichever happens first. The claims administrator may provide notices of urgent benefit determinations orally; oral notice will be followed by written notice within three days.

If such an extension is necessary because you don't submit the information necessary to decide the claim, the notice of extension will specifically describe the required information. You'll be given at least 45 days from receipt of the notice within which to provide the specified information.

If a pre-service claim isn't filed according to the plan's claim procedures, you may be notified as soon as possible, but no later than five days after the claim is received by the plan. If the claim is an urgent care case, you may be notified within 24 hours. Notice of an improperly filed pre-service claim may be provided orally, or in writing, if you request. The notice will identify the proper procedures to be followed in filing the claim.

If you request an extension of ongoing treatment, you'll be notified as soon as possible given the medical exigencies, but no later than 24 hours after the claims administrator receives your claim, as long as the request to extend treatment is submitted to the plan at least 24 hours before the end of the prescribed time period or number of treatments.

Post-service claims involve the payment or reimbursement of costs for medical care that has already been provided.

For post-service health claims, the claims administrator will notify you of an adverse determination within a reasonable period of time, but no later than 30 days after receipt of the claim. This period may be extended by 15 days if the claims administrator determines that an extension is necessary because of matters beyond the claims administrator's control and notifies you, within the initial 30-day period, of the circumstances requiring the extension and the date by which the claims administrator expects to render a decision.

If such an extension is necessary because you don't submit the information necessary to decide the claim, the notice of extension will specifically describe the required information. You'll be given at least 45 days from receipt of the notice within which to provide the specified information.

All claims for services received from an out-of-network provider should be submitted within 180 days of the date of the service. The claims administrator may deny any claims filed more than 180 days after the date of the service.

The claims administrator will notify you of its decision within 30 days after receiving the claim, unless special circumstances require an extension of time (but no later than 120 days). If the claims administrator cannot reach a decision within 30 days, you will be notified in writing of the expected date of the decision.

If you receive notice of an adverse benefit determination and you disagree with the decision, you're entitled to apply for a full and fair review of the claim and the adverse benefit determination.

If you have a concern regarding a person, a service, the quality of care or contractual benefits, you may call the number on your ID card, explanation of benefits, or claim form, and explain your concern to a Plan member services representative. You may also express that concern in writing. The claims administrator will work to address your concern within 30 days. If you are not satisfied with the results of a coverage decision, you may start the appeals process.

To initiate an appeal, you must submit a request for an appeal in writing to the claims administrator within 180 days of receipt of a denial notice. You should state the reason why you feel your appeal should be approved and include any information supporting your appeal. If you are unable or choose not to write, you may ask the claims administrator to register your appeal by telephone. Call or write them at the toll-free number on your ID card, explanation of benefits, or claim form.

Your appeal will be reviewed and the decision made by someone not involved in the initial decision. Appeals involving Medical Necessity or clinical appropriateness will be considered by a health care professional.

The claims administrator will respond in writing with a decision within 30 calendar days after they receive an appeal for a required pre-service or concurrent care coverage determination or a post-service Medical Necessity determination. The claims administrator will respond within 60 calendar days after they receive an appeal for any other post-service coverage determination. If more time or information is needed to make the determination, you will be notified in writing about the request for an extension of up to 15 calendar days and to specify any additional information needed to complete the review.

In the event any new or additional information (evidence) is considered, relied upon or generated by the claims administrator in connection with the appeal, they will provide this information to you as soon as possible and sufficiently in advance of the decision, so that you will have an opportunity to respond. Also, if any new or additional rationale is considered by the claims administrator, they will provide the rationale to you as soon as possible and sufficiently in advance of the decision so that you will have an opportunity to respond.

You may request that the appeal process be expedited if:

If you request that your appeal be expedited based on (1.) above, you may also ask for an expedited external review at the same time, if the time to complete an expedited review would be detrimental to your medical condition.

When an appeal is expedited, the claims administrator will respond orally with a decision within 72 hours, followed up in writing.

If you are not fully satisfied with the decision of the claims administrator's internal appeal review and the appeal involves medical judgment or a rescission of coverage, you may request that your appeal be referred to an Independent Review Organization (IRO). The IRO is composed of persons who are not employed by the claims administrator, or any of its affiliates. A decision to request an external review to an IRO will not affect the claimant's rights to any other benefits under the plan.

There is no charge for you to initiate an external review. The claims administrator and your benefit plan will abide by the decision of the IRO.

To request a review, you must notify the Aetna Appeals Coordinator within 4 months of your receipt of the claims administrator's appeal review denial. The claims administrator will then forward the file to a randomly selected IRO. The IRO will render an opinion within 45 days.

When requested, and if a delay would be detrimental to your medical condition, as determined by Aetna's Physician Reviewer, or if your appeal concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, but you have not yet been discharged from a facility, the external review shall be completed within 72 hours.

To initiate an appeal, you must submit a request for an appeal in writing to the claims administrator within 180 days of receipt of a denial notice.

Your request should include your name (the covered employee), your date of birth, the name of the person enrolled (i.e., your dependent if applicable), your member ID number, the provider's name and the claim number.

You are allowed to review, during normal working hours, any documents held by the claims administrator pertinent to the denial. You also may request in writing for copies of these documents. You may submit written comments or supporting documentation regarding the claim to assist in the claims administrator's review.

The claims administrator will respond within 30 days after receiving an appeal.

If you are dissatisfied with our level-one appeal decision, you may request a second review within 60 calendar days after the claims administrator's response to the initial appeal. The claims administrator will notify you of its final determination including the specific reasons for the decision in compliance with all applicable state and federal laws and regulations.

For all ERISA claims, the claims administrator or other appropriate named fiduciary will provide you with written or electronic notification of the determination on appeal. This administrative appeal process must be completed before you begin any legal action regarding your claim.

You also have the right to bring a civil action under Section 502(a) of ERISA if you are not satisfied with the decision on review of your medical, dental, or vision appeals. See "Judicial Review."

You or your plan may have other voluntary alternative dispute resolution options such as mediation. Contact your plan administrator for more information or your local U.S. Department of Labor office and your state insurance regulatory agency.