79 • Expedited Appeal Process If your claim involves urgent care, an expedited appeal may be initiated by a telephone call to Cigna Member Services located on the back of your member identification card (800 - 244 - 6224). You or your authorized representative may appeal urgent care claim denials either orally or in writing. All necessary information, including the appeal decision, will be communicated between you or your authorized representative and the Plan by telephone, fax or other similar method. You will be notified of the decision not later than 36 hours after the urgent care appeal is received. • Right to Second Level Appeal If you are dissatisfied with the appeal decision made by Cigna , you may request a second level review of your appeal. Your request for second level appeal review must be made in writing to the Board of Trustees, and be submitted to the office of the National IAM Benefit Trust Fund within 90 days of your receipt of Cigna’s denial notice on the first level appeal review. Your second level appeal should include a copy of the first level appeal denial, and any information supporting your appeal. Second leve l appeals received more than 90 d ays after receipt of the denial for the first level appeal will be denied as untimely. B. Filing a Second Level Appeal On second level, the Boa rd of Trustees will review your claim and make a decision on the date of the first meeting of the Board that immediately follows the Plan’s receipt of a request for review, unless the request for review is filed within 30 days preceding the date of such me eting. In such case, a benefit determination may be made on the date of the second meeting following the Plan’s receipt of the request for review. If special circumstances require a further extension of time for processing, a determination will be made no later than the third meeting following the initial receipt of the appeal. If an extension is required, you will be notified of the extension and the reasons for it prior to the commencement of the extension. In deciding an appeal of a benefit determinatio n that was based, in whole or in part, on a medical judgment (including determinations about whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate), the reviewer will consult with a health care professional who has appropriate training and expertise in the particular field of medicine, and who was not consulted in connection with the original determination. You will also be provided, upon request, with the identity of any medical or v ocational experts whose advice was obtained at any level of the claims and appeals process, without regard to whether that advice was relied on. If you submit an appeal with the Board of Trustee, any applicable statute of limitations will be delayed while the appeal is pending. The filing of a claim will have no effect on your rights to any other benefits under the Plan. No fees or costs are imposed upon you as part of the appeal to the Board of Trustees. The decision to submit a denial made by Cigna to th e Board of Trustees will have no effect upon your rights to any other benefits under the P lan. If you choose to appeal to the Board of Trustees following an adverse determination at the first level of appeal by Cigna, you must do so in writing, and you sho uld send the following information: • The specific reason(s) for the appeal; • Copies of all past correspondence with the Fund, including any Explanation of Benefits (EOB’s); • Copies of the adverse appeal determination made by Cigna; and • Any applicable informa tion that you have not yet sent to the Fund Office.
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