You have a right to appeal an adverse determination by the AFTRA Health Fund that involves either the denial, in whole or in part, of a specific “claim for benefits” or other issues concerning eligibility and responses to inquiries about what benefits are payable. Please refer to the AFTRA Health Fund Summary Plan Description (SPD) and relevant updates to the SPD for information about the appeals process, including where to submit your appeal, the time frames associated with the appeal process, and the information that you need to submit.

Right to review documents and obtain other information
You have the right to review, and receive free of charge upon request, documents, records or information relevant to your claim. A document, record or other information is relevant if it was relied upon in making the decision, or if it was submitted, considered or generated (regardless of whether it was relied upon) in making the decision. A document is also relevant if it demonstrates compliance with the AFTRA Health Fund’s administrative processes for ensuring consistent decision-making.

Right to independent review
A review of an adverse determination will not be by the same person who made the original determination or a subordinate of that person. A review will not afford deference to the initial determination. The decision will be made on the basis of the record, including such additional comments, documents, records or other information that you submit, even if the documents or information were not considered or submitted in connection with the original decision.

Cases involving a medical judgment
If your claim was denied on the basis of a medical judgment (such as a determination that the treatment or service was not medically necessary, or was an experimental procedure), a health care professional who has appropriate training and experience in a relevant field of medicine will be consulted. Upon request, the medical expert(s) whose advice was obtained will be identified.

You will be notified in writing once a decision is made on your appeal. If your final appeal is ultimately denied in whole or in part, you have the right to file a lawsuit under the Employee Retirement Income Security Act of 1974 (ERISA). You must exhaust the Plan’s appeals process prior to filing any lawsuit.