Steps in the Benefits Claims and Appeals Process

Step 1: Filing Your Initial Claim for Benefits

In general, when you file a claim for benefits, it is paid according to the provisions of the U.S. Fertility Benefits Program. Your initial claims must be filed no later than six months of when the expenses are incurred. Generally, in-network claims filing is performed by the physician or care provider.

Step 2: Receiving Notification from the Claims Administrator/Plan Administrator if an Initial Claim for Benefits Is Denied

What Qualifies as a "Denied Benefit"?

A "denied benefit" is any denial, reduction, or termination of a benefit, or a failure to provide or make a payment, in whole or in part, for a benefit. In addition, a benefit may be denied if you didn't include enough information with your initial claim.

If an initial claim for benefits is denied, the claims administrator or plan administrator will notify you within a "reasonable" period, not to exceed:

As soon as reasonably possible but no more than 72 hours for claims involving urgent care, where the life of a claimant could be jeopardized (may be oral, with written confirmation within three days). Please Note: You must be notified if your claim is approved or denied.

15 days for pre-service claims, where approval is required before receiving benefits, plus one 15-day extension because of matters beyond the plan's control.

30 days for post-service claims, where the claim is made after care is received, plus one 15-day extension because of matters beyond the plan's control.

Under certain circumstances, the claims administrator or Plan Administrator, as applicable, is allowed an extension of time to notify you of a denied benefit.

Please Note: If an extension is necessary because you did not submit necessary information needed to process your claim, the timing for making a decision about your claim is stopped from the date the claims administrator or plan administrator sends you an extension notification until the date that you respond to the request for additional information. You generally have 45 days from the date you receive the extension notice to send the requested information to the claims administrator or Plan Administrator.

Please Note: Concurrent care claims are claims for which the plan has previously approved a course of treatment over a period of time or for a specific number of treatments, and the plan later reduces or terminates coverage for those treatments. Concurrent care claims may fall under any of the other steps in the claims appeal process, depending on when the appeal is made. However, the plan must give you sufficient advance notice to appeal the claim before a concurrent care decision takes effect.

The Explanation You'll Receive from the Claims Administrator/Plan Administrator in the Case of a Denied Benefit

If your initial claim is denied, the claims administrator or plan administrator is legally required to provide an explanation for the denial, which will include the following:

The specific reason(s) for the denial;

References to the specific plan provisions on which the denial is based;

A description of any additional material or information needed to process your claim and an explanation of why that material or information is necessary; and

A description of the plan's appeal procedures and time limits, including a statement of your right to bring a civil action under Section 502(a) of ERISA after, and if, your appeal is denied.

If the benefit was denied based on medical appropriateness, an experimental or unproven treatment, or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the denial applying the terms of the plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request.

Any internal rule, guideline, protocol, or other similar criterion relied upon in making the benefit denial, or a statement that a copy of this information will be provided free of charge upon request.

Step 3: Filing an Appeal to the Claims Administrator/Plan Administrator if an Initial Claim for Benefits Is Denied

If you have filed a claim for benefits and your claim is denied, you have the right to appeal the decision. JPMorgan Chase is not involved in deciding appeals for any denied benefit claim under the U.S. Fertility Benefits Program.

The plan administrators delegate all fiduciary responsibility and decisions about a claim for a denied benefit under the Fertility Benefits Program to WINFertility.

Under certain plans including the U.S. Fertility Benefits Program, final appeals for denied claims will be heard by a review panel that is independent of both the company and the claims administrators.

If your initial claim for benefits is denied, you — or your authorized representative — may file an appeal of the decision with the claims administrator or plan administrator within 180 days after receipt of the claim denial.

In your appeal, you have the right to:

Submit written comments, documents, records, and other information relating to your claim.

Request, free of charge, reasonable access to, and copies of, all documents, records, and other information that:

Was relied upon in denying the benefit.

Was submitted, considered, or generated in the course of denying the benefit, regardless of whether it was relied on in making this decision.

Demonstrates compliance with the administrative processes and safeguards required in denying the benefit.

For health care: constitutes a policy statement or plan guideline concerning the denied benefit regardless of whether the policy or guideline was relied on in denying the benefit.

You also have the right to receive:

A review that does not defer to the initial benefit denial and that is conducted by someone other than the person who made the denial or that person's subordinate.

For a denied benefit based on medical judgment (including whether a particular treatment, drug, or other item is experimental or unproven), a review in which the plan fiduciary/claims administrator consults with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment, and who was not consulted in connection with the initial benefits denial, nor the subordinate of this person.

The identification of medical or vocational experts whose advice was obtained in connection with denying the benefit, regardless of whether the advice was relied on in making this decision.

In the case of an urgent care claim where the life of a claimant could be jeopardized, an expedited review process in which:

You may submit a request (orally or in writing) for an expedited appeal of a denied benefit.

All necessary information, including the decision on your appeal, will be transmitted between the plan fiduciary/claims administrator and you by telephone, facsimile, or other available similarly prompt method.

Step 4: Receiving Notification from the Claims Administrator/Plan Administrator if Your Appeal Is Denied

If your appeal is subsequently denied, the claims administrator or plan administrator is legally required to notify you in writing of this decision within a "reasonable" period of time according:

As soon as reasonably possible but no more than 72 hours for claims where the life of a claimant could be jeopardized (urgent care)

15 days where approval is required before receiving benefits (pre-service claims)

30 days where the claim is made after care is received (post-service claims)

The claims administrator or the plan administrator is allowed to take an extension to notify you of a denied appeal under certain circumstances. If an extension is necessary, the claims administrator or plan administrator will notify you before the end of the original notification period. This notification will include the reason(s) for the extension and the date the claims administrator or the plan administrator expects to provide a decision on your appeal for the denied benefit. Please Note: If an extension is necessary because you did not submit enough information to decide your appeal, the time frame for decisions is stopped from the date the claims administrator or the plan administrator sends you an extension notification until the date that you respond to the request for additional information.

The Explanation You'll Receive from the Claims Administrator/Plan Administrator in the Case of a Denied Benefit

If an appeal is denied, the claims administrator or plan administrator is legally required to provide an explanation for the denial, which will include the following:

The specific reason(s) for the denial;

References to the specific plan provisions on which the denial is based;

A statement that you're entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits; and

A statement describing any appeal procedures offered by the plan and your right to obtain the information about such procedures, and a statement of your right to bring a civil action under ERISA.

If the benefit was denied based on medical appropriateness, experimental, or unproven treatment, or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the denial applying the terms of the plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request.

A description of the expedited review process for urgent care claims in the Medical Plan, where the life of the claimant could be jeopardized.

The U.S. Fertility Benefits Program requires two levels of appeal, which you must complete if you would like to pursue your claim further.

Step 5: Receiving a Final Appeal by an Independent Review Panel

If your appeal of a benefits claim is denied, your final appeal for coverage will be heard by a review panel that is independent of both the company and the claims administrator.

The independent review panel hears only appeals that involve medical judgment or a rescission of coverage; the panel does not hear appeals about eligibility to participate in a plan or legal interpretation of a plan that does not involve medical judgment.