Procedures for Appealing Claims under Lumenos Georgia Health Insurance

Claims Review and Appeals Procedures

Step 1: Notice is received from Claims Administrator. If your claim is denied, you will receive written notice from the Claims Administrator that your claim is denied (in the case of urgent claims, notice may be oral). The time frame in which you will receive this notice is described in the chart below and will vary depending on the type of claim. In addition, the Claims Administrator may obtain an extension of time in which to review your claim if necessary for reasons beyond the Claims Administrator's control. If the reason for the extension is that you need to provide additional information, you will be given a certain amount of time in which to obtain the requested information (it will vary depending on the type of claim). The time period during which the Claims Administrator must make a decision will be suspended until the earlier of the date that you provide the information or the end of the applicable information gathering period.

Step 2: Review your notice carefully. Once you have received your notice from the Claims Administrator, review it carefully. The notice will contain:

• the reason(s) for the denial and the Plan provisions on which the denial is based;
• a description of any additional information necessary for you to perfect your cotelaim, why the information is necessary, and your time limit for submitting the information;
• a description of the Plan's appeal procedures and the time limits applicable to such procedures, including a statement of your right to bring a civil action following a denial of your appeal;
• a statement indicating whether an internal rule, guideline or protocol was relied upon in making the denial and that a copy of that rule, guideline or protocol will be provided free of charge upon request;
• if the denial is based on a medical necessity, experimental treatment or a similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination or a statement that such explanation will be provided free of charge upon request; and
• if the claim was an Urgent Care Claim, a description of the expedited appeal process. The notice may be provided to you orally; however, a written or electronic notification will be sent to you not later than three days after the oral notification.

Step 3: If you disagree with the decision, file a 1st Level Appeal with the Claims Administrator.If you do not agree with the decision of the Claims Administrator, you may file a written appeal with the Claims Administrator within 180 days of receipt of the Claims Administrator's letter (or oral notice if an urgent care claim) referenced in Step 1. If the claim involves urgent care, your appeal may be made orally. In addition, you should submit all information identified as necessary to perfect your claim that is referenced in the Notice described in Step 2 with your appeal. You should gather any additional information that is identified in the notice as necessary to perfect your claim and any other information that you believe will support your claim. Your request for appeal must include the following:

• the patient's name and identification number
• the date of the medical service
• the provider's name
• the reason you believe the claim should be paid, and
• any documentation or other written information to support your request for claim payment.

All appeals will be processed as described below.

All appeals should be sent to:
Lumenos
1801 North Beauregard Street, Suite 10
Alexandria, Virginia 22311-1701
Attention: Appeals Department

Step 4: 1st Level Appeal notice is received from Claims Administrator. If the claim is again denied, you will be notified by the Claims Administrator within the time period described in the chart below depending on the type of claim.

Step 5: Review your notice carefully. You should take the same action that you take in Step 2 described above. The notice will contain the same type of information that is provided in the first notice of denial provided by the Claims Administrator.

Step 6: If you still disagree with the Claims Administrator's decision, file a 2nd Level Appeal with the Claims fiduciary. If you still do not agree with the Claims Administrator's decision, you may file a written appeal to the Claims fiduciary within 60 days after receiving the first level appeal denial notice from the Claims Administrator. You should gather any additional information that is identified in the notice as necessary to perfect your claim and any other information that you believe will support your claim. The appeal should be sent to:

Lumenos
1801 North Beauregard Street, Suite 10
Alexandria, Virginia 22311-1701
Attention: Appeals Department

If the Claims fiduciary denies your 2nd Level Appeal, you will receive notice within the time period described in the chart below, depending on the type of claim. The notice will contain the same type of information that was referenced in Step 1 above.

Important Information

Other important information regarding your appeals:

• Each level of appeal will be independent from the previous level (i.e. the same person(s) or subordinates of the same person(s) involved in a prior level of appeal will not be involved in the appeal);
• On each level of appeal, the claims reviewer will review relevant information that you submit even if it is new information;
• If an appeal involves medical judgment, then the Claims Administrator and the Claims fiduciary will consult during the 1st and 2nd level appeals with an independent health care professional who has expertise in the specific area involving medical judgment.
• While it is your option to appeal, you cannot file suit in federal court until you have exhausted these appeals procedures.