HomeMy WebLinkAboutContracts & Agreements_211-2002Effective January 1, 2003 the Plan Document for CITY OF REDLANDS Group Dental Plan is
amended to reflect the following changes:
Delete the CLAIMS PROCEDURES section in its entirety and replace it with:
It is the intent of the Plan Administrator that the following claims procedures comply with the
United States Department of Labor ("DOL") regulation , 29 CFR § 2560.503-1, and the
Employee Retirement Income Security Act of 1974, as amended ("ERISA"). Where any provision
is in conflict with the DOL's claims procedure regulations, ERISA, or any or any other
applicable law, such law shall control.
SUBMITTING A CLAIM
A claim is a request for benefit determination made, in accordance with the Plan's procedures,
by a Claimant or his authorized representative. A claim must be received by the person or
organizational unit customarily responsible for handling benefit matters on behalf of the Plan
so that the claim review and benefit determination process can begin. A claim must name the
Plan, a specific Claimant, a specific health condition or symptom or diagnostic code, and a
specific treatment, service or supply (or procedure/ revenue codes) for which a benefit or benefit
determination is requested, the date of service, the amount of charges, the address (location)
where services are received, and provider name, address, phone number and tax identification
number.
For purposes of the Plan, the Plan Administrator, at its discretion, may contract with other
entities to handle claims communications and benefit determinations for the Plan. Such other
entities may include an insurance company, a '-third party claims payer, a managed care
organization, or a pharmacy benefit manager. Contact information for such entities is provided
below.
There are two types of claims: (1) Pre -Service Claims, and (2) Post -Service Claims:
1). A Pre -Service Claim is a written or oral request for benefit determination where the terms of
the Plan condition benefits, in whole or in part, on prior approval of the proposed care (e.g., a
dental pre-treatment review requirement),
Important: A benefit determination for a Pre -Service Claim shall only be for the purposes
of assessing the Medical Necessity and appropriateness of care and delivery setting. A
benefit determination for a Pre -Service Claim is not a guarantee of benefits from the
Plan. Plan benefit payments are subject to review upon submission of a claim to the Plan
after dental services have been received, and are subject to all related Plan provisions,
including exclusions and limitations. Further, where the Plan does not require prior
approval, a request for advance information on the Plan's possible coverage of an item •
service, or advance approval of a covered item or service, does not constitute a Pre -
Service Claim.
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2). A Post -Service Claim is a written request for benefit determination after a service has been
rendered and expense has been incurred. A Post -Service Claim must be submitted to the
claims office within Twelve (12) months from the date the expense was incurred.
PROCEDURES FOR SUBMITTING A CLAIM
A Pre -Service Claim should be submitted to:
Affordable Benefit Administrators, Inc.
P. 0. Box 10787
Burbank, CA. 91510
(818) 842-0147 or (800) 350-0148
A Post -Service Claim should be submitted to:
A
P. 0. Box 10787
Burbank, CA. 91510
(818) 842-0147 or (800) 350-0148
Note: In accordance with federal law, the Centers for Medicare and Medicaid Services (CMS)
have three (3) years to submit claims when Medicare has paid as the primary plan and the Plan
should have been primary.
ASSIGNMENTS TO PROVIDERS
All Eligible Expenses reimbursable under the Plan will be paid to the covered Employee except
that: (1) assignments of benefits to Hospitals, Physicians or other providers of service will be
honored, (2) the Plan may pay benefits directly to providers of service unless the Covered
Person requests otherwise, in writing, within the time limits for filing proof of loss, and (3) the
Plan may make benefit payments for a child covered by a Qualified Medical Child Support
Order (a QMCSO) directly to the custodial parent or legal guardian of such child.
Notwithstanding any assignment or non -assignment of benefits to the contrary, upon payment
of the benefits due under the Plan, the Plan is deemed to have fulfilled its obligations with
respect to such benefits, whether or not payment is made in accordance with any assignment
or request.
No covered Employee or Dependent may, at any time, either while covered under the Plan or
following termination of coverage, assign his rights to sue to recover benefits under the Plan, or
enforce rights due under the Plan or any other causes of action which he may have against the
Plan or its fiduciaries.
Note: Benefit payments on behalf of a Covered Person who is also covered by a state's Medicaid
program will be subject to the state's right to reimbursement for benefits it has paid on behalf
of the Covered Person, as created by an assignment of rights made by the Covered Person or
his beneficiary as may be required by the state Medicaid plan. Furthermore. the Plan will honor
any subrogation rights the state may have gained from Medicaid -eligible beneficiary due to the
state's having paid Medicaid benefits that were payable under the Plan.
CLAIMS TIME LIMITS AND ALLOWANCES
For group health plans subject to the Employee Retirement Income Security Act (ERISA), the
chart below sets forth the time limits and allowance that apply to the Plan ar�d a Claimant with
respect to claims filings, administration and benefit determinations. If there is anv variance
betw,een the following information and the intended requirements of the law, the law will
prevail.
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In the case of a Plan established and maintained pursuant to a collective bargaining
agreement, such Plan will be deemed to comply with ERISA's claims requirements if the
bargaining agreement sets forth or incorporates by reference: (1) provisions concerning the
filing of claims and the initial disposition of claims, and (2) a grievance and arbitration
procedure to which adverse benefit determinations are subject. If the bargaining agreement
includes only grievance and arbitration procedure, then the provisions included herein
concerning the filing and initial disposition of claims will apply but the appeal procedures will
be superseded by the terms of the bargaining agreement.
Important: The stated claims procedures herein address the periods within which claims
determinations must be decided, not paid. Benefit payments must be made within
reasonable periods of time following Plan approval as governed by ERISA.
Urgent Claim - defined below
Claimant Makes Initial Incomplete
Claim Request
Plan Receives Completin Information
Claimant Makes Initial Complete Claim
Request
Plan Responds to Appeal
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Within not more than 24 hours (and as soon as
possible taking into account the medical exigencies),
Plan notifies Claimant of material needed to complete
the claim request. Notification may be oral unless
Claimant requests a written notice. Claimant will
have a reasonable period of time, but not less than 48
hours, to provide the required information to
complete the claim.
Plan notifies Claimant, in writing or electronically, of
its benefit determination as soon as possible and not
later than 48 hours after the earlier of: (1) receipt of
the completing information, or (2) the period of time
Claimant was allowed to provide the completing
information. Oral notice can be given in addition to
written or electronic notice. Written or electronic
notice of a benefit denial or reduction (an "adverse
benefit determination '') must be provided to the
Claimant not later than 3 days after oral notification.
Within not more than 72 hours (and as soon as
possible taking into account the medical exigencies),
Plan responds with written or electronic benefit
determination. Oral notice can be given in addition to
written or electronic notice. Written or electronic
notice of a benefit denial or reduction (an "adverse
benefit determination") must be provided to the
Claimant not later than 3 days after an oral
notification.
See "Appeal Procedures" subsection. An appeal for an
urgent claim may be made orally or in writing.
Within not more than 72 hours (and as soon as
possible taking into account the medical exigencies),
after receipt of Claimant's appeal.
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An "urgent claim" is an oral or written request for benefit determination where the decision
would result in either of the following if decided within the time frames for non -urgent claims:
(1) serious jeopardy to the Claimant's life or health, or the ability to regain maximum function,
or (2) in the judgment of a Physician knowledgeable about the Claimant's condition, severe
pain that could not be adequately managed without the care or treatment being claimed. All
necessary information, including the Plan's handling of an appeal, shall be transmitted
between the Plan and the Claimant by telephone, facsimile or other available and similar
expeditious methods.
Whether a claim is urgent will generally be decided by an individual acting on behalf of the
Plan and applying the judgment of a prudent layperson who possesses an average knowledge of
health and medicine. However, if a Physician familiar with the Claimant's condition decides
that the claim involves urgent care, the Plan must defer to the Physician's judgment.
NOTE: THE BENEFIT DETERMINATION TIME FRAMES STATES ABOVE SHALL BEGIN AT THE
TIME A CLAIM IS FILED IN ACCORDANCE WITH THE PROCEDURES OF THE PLAN,
WITHOUT REGARD TO WHETHER ALL THE INFORMATION NECESSARY TO MAKE A
BENEFIT DETERMINATION ACCOMPANIES THE FILING.
"PRE -SERVICE" CLAIM ACTIVITY I TIME LIMIT OR ALLOWANCE
Concurrent Care Claim - defined below I
Plan Makes an Adverse Claim Decision Plan notifies Claimant of intent to reduce or deny
benefits before any reduction or termination of
benefits is made and provides enough time to allow
the Claimant to appeal and obtain a determination
on review before the benefit is reduced or
terminated. Any decision with the potential of
causing disruption to ongoing care which is
Medically Necessary, is subject to the urgent claim
rules.
Claimant Requests Extension for Plan notifies Claimant of its benefit determination
Urgent Care within not more than 24 hours after receipt of the
request (and as soon as possible taking into account
the medical exigencies), provided such request is
made at least 24 hours prior to the expiration of the
previously -approved period of time or treatment.
Otherwise, the Plan's notification must be made in
accordance with the time allowances for appeal of an
urgent, pre -service or post -service claim, as
appropriate.
A "concurrent care claim" is a Claimant's request to extend a previously -approved ongoing
course of treatment (e.g., kidney dialysis) beyond the approved period of time or number of
treatments. An adverse claim decision for concurrent care does not include a benefit reduction
or denial due to Plan amendment or termination.
City of Redlands
Non -Urgent Claim - defined below
Claimant Makes Initial Incomplete Within 5 days of receipt of the incomplete claim
Claim Request
request, Plan notifies Claimant, orally or in writing,
of material needed to complete the claim request.
Claimant may request a written notification.
Claimant has at least 45 days from receipt of such
notice to provide required information.
Plan Receives Completing Information Within 15 days, Plan responds with written or
electronic benefit determination. 15 additional days
may be allowed with full notice to Claimant - see
definition of "full notice" below.
Claimant Makes Initial Complete Claim 1 Within 15 days, Plan responds with written or
Request electronic benefit determination. 15 additional days
I may be allowed with full notice to Claimant.
Claimant Appeals I See "Appeal Procedures" subsection.
Plan Responds to Appeal Within 30 days after receipt of appeal (or where Plan
provides for 2 levels of appeal, within 15 days for
each appeal).
"Full notice" means that notice is provided to the Claimant describing the circumstances
requiring the extension of time and the date by which the Plan expects to render a decision.
Such extension must be necessary due to matters beyond the control of the Plan and
notification to Claimant must occur prior to the expiration of the initial 15-day period.
In the case of any extension as outlined above, the notice of extension which is provided to the
Employee or Claimant shall specifically explain the standards on which entitlement to a benefit
is based, the unresolved issues that prevent a decision on the claim, and the additional
information needed to respond to those issues. Where the Contract Administrator requires
additional information of the Employee or Claimant, the Contract Administrator must afford
the Employee or Claimant at least 45 days to provide the specific information. In such case, the
benefit determination period will be tolled (suspended) from the date on which notification of
the extension is sent to the Employee or Claimant until the date on which the response to the
request for additional information is made.
Claimant Makes Initial Incomplete
Claim Request
Plan Receives Completing Information
Claimant Makes Initial Complete Claim
Request
Within 30 days (and sooner if reasonably possible),
Plan advises Claimant of material needed to
complete the claim request. The Plan may extend
this period for up to 15 days with full notice to the
Claimant - see definition of "full notice" below.
Claimant has at 'least 45 days to provide required
information,
Within 30 days, Plan approves or denies claim. 15
additional days may be allowed with full notice to
Claimant - see definition of "full notice" below.
Within 30 days of'receiving the claim, Plan approves
or denies claim. 15 additional days may be allowed
with full notice to Claimant - see definition of "full
notice" below.
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Claimant Appeals i
Plan Responds to Appeal Within 60 days after receipt of appeal (or within 30
days for each appeal if Plan provides for two appeal
levels).
"Full notice" means that notice is provided to the Claimant describing the circumstances
requiring the extension of time and the date by which the Plan expects to render a decision.
Such extension must be necessary due to matters beyond the control of the Plan and
notification to Claimant must occur prior to the expiration of the initial 30-day or 60-day
period.
In the case of any extension as outlined above, the notice of extension which is provided to the
Employee or Claimant shall specifically explain the standards on which entitlement to a benefit
is based, the unresolved issues that prevent a decision on the claim, and the additional
information needed to respond to those issues. Where the Contract Administrator requires
additional information of the Employee or Claimant, the Contract Administr-ator must afford
the Employee or Claimant at least 45 days to provide the specific information. In such case, the
benefit determination period will be tolled (suspended) from the date on which notification of
the extension is sent to the Employee or Claimant until the date on which the response to the
request for additional information is made.
ADMINISTRATIVE PROCESSES AND SAFEGUARDS
The Plan • that claims determinations be made in accordance with governing
documents of the Plan and that they • applied • with respect to similarly situated
Claimants. The claims procedures will not be administered in a way that unduly inhibits or
hampers the initiation or processing of claims or claims appeals.
AUTHORIZED REPRESENTATIVE MAY ACT FOR CLAIMANT
Any of the above actions which can be done by the Claimant can also be done by an authorized
representative acting on the Claimants behalf. The Claimant may be required to provide
reasonable proof of such authorization. For an urgent claim, a health care professional, with
knowledge of a Claimant's medical condition, will be permitted to act as the authorized
representative of the claimant. "Health care professional" means a physician or other health
care professional licensed, accredited, or certified to perform specified health services
consistent with state law.
BENEFIT DETERMINATIONS
Upon the Contract Administrator's receipt of a written claim for benefits and pursuant to the
procedures described herein, the Contract Administrator will review the claim submission,
proof of claim, and all associated and / or applicable information provided by the Claimant and
gathered independently by the Contract Administrator in light of the Plan Document through
which benefits of the Plan are paid - Further, the Contract Administrator will assure that all
benefit determinations are applied consistently to similarlv-situated Plan participants by
maintaining appropriate claim and benefit records which shall be reviewed periodically and on
a case -by -case basis to determine past practices in similar claim situations. Documentation of
such reviews shall be made available to the Employee or Claimant upon request. Should the
Contract Administrator at any time during its revieur period determine that additional
information is required from th� Employee or Claimant, the Contract Administrator will request
such necessary information from the Employee. The Contract Administrator will make every
effort to make its benefit determination in as reasonable a time frame as possible.
CAL
For benefit determination, the period of time within which such determination is required
begins at the time a claim is filed in accordance with the Plan's reasonable procedures, without
SHIM80=
regard to whether all the information necessary to make a benefit determination accompanies
the filing. In the event that an extended period of time is permitted due to a Claimant's failure
to submit necessary information, the period for making the determination will be tolled
(suspended) from the date on which the notification of the extension is sent to the Claimant
until the date on which the Claimant responds to the request for additional information.
WRITTEN OR ELECTRONIC NOTICES
The Plan shall provide a Claimant with written or electronic notification of any benefit
reduction or denial. Written or electronic notice of an approved benefit must be provided only
for Pre -Service benefit determinations.
"Notice" or "notification" means the delivery or furnishing of information in a manner that
satisfies the standards of 29 CFR 2520.104b-l(b) as appropriate with respect to material
required to be furnished or made available to an individual. Anv electronic notification shall
comply with the standards of 20 CFR 2520.104b-(c)(1)(i), (ii), (iii), and (iv) and 2520.104b-
l(c)(2)(i) and (ii).
CLAIMS DENIALS
If a claim is wholly or partially denied (see NOTE), the Claimant will be given written or
electronic notification of such denial within the time frames required by law (see Claims Time
Limits and Allowances). The notice will include the following and will be provided in a manner
intended to be understood by the Claimant:
the specific reason(s) for the decision to reduce or deny benefits;
specific reference to the Plan provision(s) on which the denial is based as well as
identification of and access to any guidelines, rules, and protocols which were relied
upon in making the decision. Where a Plan utilizes a specific internal rule or protocol,
the notice may wither set forth the protocol or included a statement that a copy of such
protocol will be furnished to the Claimant or his authorized representative free of charge
and upon request. A notification of denial or benefit reduction based on Medical
Necessity or experimental treatment or other similar exclusion or limit must explain the
scientific or clinical judgment of the Plan in applying the terms of the Plan to the
Claimant's medical circumstances, or must included a statement that such explanation
will be provided to the Claimant free of charge upon request;
a statement that the Claimant is entitled to receive, upon request and free of charge,
reasonable access to, and copies of, all documents, records or other information
relevant to the Claimant's claim for benefits;
the identity of any medical or vocational experts consulted in connection with the claim,
even if the Plan did not rely upon their advice, or a statement that the identity of the
expert(s) will be provided upon request;
a description of any additional information needed to change the decision and an
explanation of why it is needed;
a description of the Plan's procedures and time limits for appealed claims, including a
statement of the Claimant's right to bring civil action under section 502(a) of ERISA. A
denial of an urgent claim must describe the expedited appeal process for urgent health
claims. An urgent claim denial may be made orally to the Claimant if a written or
electronic notification is furnished to the Claimant within 3 days after the oral
notification.
NOTE: A claim denial, or an "adverse benefit determination", means any of the following: a
denial, reduction (which includes anv instance where the Plan pays less than the total amount
City of Redlands
of expenses submitted with regard to a claim), termination of a benefit, or a failure to provide
or make payment (in whole or in part) for a benefit, including any such denial, reduction,
termination or failure to provide or make payment that is based on a determination of a
participant's or beneficiary's eligibility to participate n a plan, and including denial, reduction,
or termination of a benefit, or failure to provide or make payment, in whole or in part for a
benefit resulting from the application of any utilization review, as well as a failure to cover an
item or service for which benefits are otherwise provided because it is determined to be
experimental or investigational or not Medically Necessary or appropriate.
Denial of a claim for failure to obtain a prior approval under circumstances that would make
obtaining such prior approval impossible or where application of the prior approval process
could seriously jeopardize the life or health of the patient (e.g., the patient is unconscious and
is in need of immediate care at the time medical treatment is required) is prohibited.
APPEAL PROCEDURES
FILING AN APPEAL AND APPEAL REVIEW
Within 180 days of receiving notice of a claim reduction or denial, a Claimant may appeal his
claim, in writing, to a new decision -maker (an appropriate Named Fiduciary of the Plan who is
neither the individual who made the initial adverse benefit determination nor a subordinate of
the initial decision -maker) and he may submit new information (comments, documents,
records, etc.) in support of his appeal.
In response to his appeal, the Claimant is entitled to a full and fair review of the claim and a
new decision and not simply a review whether the initial decision was reasonable. A "full and
fair review" takes into account all comments, documents, records and other information
submitted by the Claimant relating to the claim, without regard to whether the information was
submitted or considered in the initial determination.
At such time as the Claimant appeals a denied claim, he will be provided, upon request and
free of charge, with access to and copies of all documents, records and other information
relevant to his claim for benefits, without regard to whether the Plan relied on the material. The
Plan will also disclose the names of any medical or health professionals consulted as part of
the claim process, whether or not such information was submitted or considered in the initial
benefit determination.
For appeal of a denial based in whole or in part on a medical judgment, including
determinations with regard to whether a particular treatment, drug or other item is
experimental, investigational, or not Medically Necessary or appropriate, the new decision -
maker shall consult with an independent health care professional who has appropriate training
and experience in the field of medicine involved in the medical judgment. Such professional
must be independent of any health care professional involved in the initial decision to reduce
or deny benefits. "Health care professional" means a physician or other health care professional
licensed, accredited, or certified to perform specified health services consistent with state law.
DECISIOA 011 APPEAL
A decision with regard to the claim appeal will be made within the allowed time frame (see
Claims Time Limits and Allowances). If special circumstances which are out of the Plan's
control, require an extension of time, written notice of the extension will be furnished to the
Claimant prior to the termination of the initially -allowed time. The extension notice will explain
the special circumstances requiring an extension and the date the Plan expects to render the
final decision. No extension is permitted for urgent claims.
The decision on appeal will be in writing or be electronic notification. With respect to an urgent
care claim, the decision may be provided by phone, facsimile or other available and similarly
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expeditious method. If the decision is to continue to reduce or deny benefits, the notification
will be provided in a manner calculated to be understood by the Claimant and will include:
the specific reason(s) for the decision;
reference to the pertinent Plan provision on which the decision is based;
a statement that the Claimant is entitled to receive, upon request and free of charge,
reasonable access to and copies of all documents, records, and other information
relevant to the claim "Relevant" information includes a document, record or other
information which: (1) was relied upon in making the benefit determination, (2) was
submitted, considered or generated in the course of making the benefit determination,
whether or not it was relied upon, (3) demonstrates compliance with the administrative
processes and safeguards required in making the benefit determination, or (4)
constitutes a statement of policy or guidance with respect to the Plan concerning the
denied benefit for the Claimant's diagnosis, whether or not it was relied upon. The Plan
will also disclose any documents that were created or received by the Plan during the
appeal process;
identification of an medical or vocational experts whose advice was obtained in
connection with the initial claim denial, whether or not the advice was relied upon in
making the initial decision;
identification of and access to any guidelines, rules, protocols which were relied upon in
making the decision. Where a Plan utilizes a specific internal rule or protocol, the
notice may either set forth the protocol or include a statement that a copy of such
protocol will be furnished to the Claimant or his authorized representative free of charge
and upon request. A notification of denial or benefit reduction based on Medical
Necessity or experimental treatment or other similar exclusion or limit must explain the
scientific or clinical judgment of the Plan in applying the terms of the Plan to the
Claimant's medical circumstances, or must include a statement that such explanation
will be provided to the Claimant free of charge upon request;
a statement describing any voluntary appeal procedures offered bv the Plan, the
Claimant's right to obtain the information about such procedure, and a statement of the
Claimant's right to bring an action under ERISA section 502(a).
In accordance with Federal law, the Plan cannot require mote than two (2) levels of mandatory
appeal. If more than one (1) level of mandatory appeal is required, both must be completed
within the time frame applicable to one(l) level.
VOLUNTARY ADDITIONAL LEVELS OF APPEAL
Subject to the Plan Administrator's established procedures, up to two (2) voluntary additional
levels of appeal (including arbitration or any other form of dispute resolution) are permitted,
but only after exhaustion of the Plan's mandatory appeal procedure.
A Claimant cannot be required to pursue any voluntary level of appeal and a voluntary level of
appeal cannot stop the Claimant from filing suit. The Plan waives any right to assert that a
Claimant has failed to exhaust administrative remedies because the Claimant did not elect to
pursue a voluntary level of appeal. Any statute of limitations or other defense based on
timeliness is tolled (suspended) while a voluntary appeal is in process or pending.
A Claimant may contact the Plan Administrator to determine if a voluntary appeal level is part
of the Plan's written procedures and, upon request, the Claimant will be provided with: (1)
sufficient information relating to the voluntary level of appeal to enable him to make an
informed judgment about whether to submit a benefit dispute to the voluntary level of appeal,
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including a statement that his decision as to whether or not to use a voluntary level of appeal
will have no effect on his rights to any other benefits under the Plan, (2) information about the
applicable rules, (3) notice of his right to representation, (4) the process for selecting the
decision -maker, and (5) the circumstances, if any, that may affect the impartiality of the
decision -maker, such as any financial or personal interests in the result or any past or present
relationship with any party to the review process. No fees or costs may be imposed on the
Claimant as part of the voluntary level of appeal.
NOTE: Arbitration is permitted as a level of appeal, but only if the Claimant is provided with
full disclosure regarding the process, arbitrator, relationships, right to representation, and only
if Claimant agrees to such arbitration after completing the internal appeal process. Mandatory
arbitration is permitted only as a mandatory appeal level. However, a Claimant is not
precluded from challenging the decision under Section 502(c) of ERISA (Employee Retirement
Income Security Act) or other applicable law.
WHEN THE NAMED FIDUCIARY IS A COMMITTEE OR BOARD OF TRUSTEES
If the Plan's Named Fiduciary is a committee or board of trustees that holds regularly -
scheduled meetings at least quarterly, the Named Fiduciary shall made a benefit determination
not later than the meeting date that immediately follows the Plan's receipt of an appeal, unless
the appeal is filed within thirty (30) days preceding the date of such meeting. In that case, a
benefit determination may be made not later than the date of the second meeting following the
Plan's receipt of the appeal. If special circumstances (such as the need to hold a hearing as is
permitted by the Plan) require a further extension of time for processing, a, benefit
determination shall be rendered not later than the third meeting following the Plan's receipt of
the appeal. If such an extension of time for review is required because of special
circumstances, the Employee will be provided with written notice of the extension describing
the special circumstances and the date on which the benefit determination will be made. Such
notice will be provided prior to the commencement of the extension. When benefit
determination is made, notice of the decision will be provided to the Employee not later than
five (5) days thereafter.
December 17, 2002
Signature of Authorized Representative Date
Karl N. Haws, Mayor
Lorri;d Poyzer, 5 0_ lerk
I
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