Notice of Claim Decision

Notice of an adverse claim determination will be provided in writing in a culturally and linguistically appropriate manner and will include:

• the reasons for the denial, with reference to the specific provisions of the plan on which the denial was based;
• a description of any additional information needed to process the claim with an explanation of why the additional information is necessary;
• and an explanation of the claims review procedure.

Upon request and free of charge, you will be provided a copy of any internal rule, guideline, protocol, or other similar criterion that was relied upon in making the adverse determination regarding the claim, and an explanation of the scientific or clinical judgment for a determination that is based on a medical necessity, experimental treatment or other similar exclusion or limit.