Coverage Options Welfare Benefit Contract Information Eligibility requirements Employee Premium Cost For More Information All One Health N/A All active FTEs and PTEs Non-Contributory 190 North Main St. Natick, MA 01760 (781) 935-8581 Flexible Benefits Feature Coverage Options Welfare Benefit Contract Information Eligibility requirements Employee Premium Cost For More Information Crosby/WageWorks N/A All active FTEs and PTEs Based on coverage selected (877) 924-3967 https://www.wageworks.com/ Health Savings Account Feature Coverage Options Welfare Benefit Contract Information Eligibility requirements Employee Premium Cost For More Information Crosby/WageWorks N/A All active FTEs enrolled in the CareLink Advantage PPO H.S.A Saver $1,500 Deductible Plan N/A (877) 924-3967 https://www.wageworks.com/ Voluntary Legal Insurance Feature Coverage Options Welfare Benefit Contract Information Eligibility requirements Employee Premium Cost For More Information Hyatt Legal Plans (A MetLife Company Life Insurance Company) MetLaw – 990/0397 Full-Time and employees working at least 17.5 hours per week. Monthly $21 per month 1111 Superior Avenue, Suite 800 Cleveland, OH 44144 Schedule B: Default ERISA Claims and Appeal Procedure Claims Procedure for Disability Benefits The following claims procedure will apply specifically to claims made for disability benefits under one or more Plan features. To the extent that this procedure is inconsistent with the claims procedures contained in the policies, contracts, summary plan descriptions or other
the specific reason(s) for your adverse benefit determination; reference to the specific Plan provision on which the determination is based; a description of any additional material or information necessary for you to fix your claim and an explanation of why such material or information is necessary; a description of the review procedures, including a statement of your right to bring a lawsuit following an adverse benefit determination on review; either the specific rule or guideline used in making your benefits determination or a statement that such a rule or guideline was relied upon in making the determination and that a copy of such rule or guideline will be provided free of charge upon request; if the adverse benefit determination is based on a medical judgment, either an explanation of such judgment, or a statement that such explanation will be provided to you free of charge upon request; and in the case of an Urgent Care Claim, a description of the expedited review process to which you may be entitled. In addition to the notice standards described above, to the extent required by the Affordable Care Act, all adverse benefit determination notices will include the following: (a) information identifying the claim involved, including the date of service, the health care provider, the claim amount, the diagnosis code, the treatment code, and the corresponding meaning of those codes; (b) the reason or reasons for the adverse benefit determination that includes the denial code and its corresponding meaning and a description of the Plan’s standard, if any, that was used to deny the claim (for notices of final internal adverse benefit determinations, the description will include a discussion of the decision); (c) a description of available internal appeals and external review processes, including how to initiate an appeal; and (d) contact information for any applicable office of health insurance consumer assistance or ombudsman established under the Affordable Care Act to assist individuals with the internal claims and appeals and external review processes. How to Appeal a Claim Decision If you disagree with a claim determination, you can contact the Plan Administrator in writing to formally request an appeal. If the appeal relates to a claim for payment, your request should include: The patient’s name and the identification number from the ID card. The date(s) of health care service(s). The provider’s name. The reason you believe the claim should be paid. Any documentation or other written information to support your request for claim payment.