72 Right to an Authorized Representative In making a claim or appeal, you may be represented by any authorized representative. If your representative is not an attorney, parent, or court appointed guardian, y ou must designate the representative by a signed written statement. For this purpose, an authorized representative also includes a health care professional. An “authorized representative” means a person you authorize, in writing, to act on your behalf, such as your Spouse. The Plan will also recognize a court order giving a person authority to submit claims on your behalf, except that in the case of a claim involving urgent care, a health care professional with knowledge of your condition may always act as your authorized representative. A form can be obtained from the Fund Office to designate an authorized representative. The Plan requires you to provide a written statement declaring your designation of an authorized representative along with the represe ntative’s name, address, phone number, and email address. To designate an authorized representative, you must submit a completed authorized representative form. The Plan will honor the designated authorized representative until the designation is revoked, or as mandated by a court order. You may revoke a designated authorized representative status by submitting a completed change of authorized representative form available from and to be returned to the appropriate Claims Administrator or the Fund Office. The Plan reserves the right to withhold information from a person who claims to be your authorized representative if there is suspicion about the qualifications of that individual. Adverse Benefit Determination An adverse benefit determination, for the pu rpose of the internal claims and appeal process, means: • A denial, reduction, or termination of, or a failure to provide or make payment in whole or in part for a benefit, including a determination of an individual’s eligibility to participate in the Plan o r a determination that a benefit is not a covered benefit; • A reduction of a benefit resulting from the application of any utilization review decision, source - of - injury exclusion, network exclusion, or other limitation on an otherwise covered benefit or fa ilure to cover an item or service for which benefits are otherwise provided because it is determined to be not medically necessary or appropriate, or Experimental or Investigational; or • A rescission of coverage, whether or not there is an adverse effect on any particular benefit. Health Care Professional A healt h care professional, for the purposes of the claims and appeals provisions, means a physician or other health care professional licensed, accredited or certified to perform specified health serv ices consistent with state law. Definition of a Claim A claim is a request for a Plan benefit made by you, your Spouse, or your covered Dependent Child (also referred to as “claimant”) or your authori zed representative in accordance with the Plan’s reasonable claims procedures. Casual inquiries about benefits or the circumstances under which benefits might be paid according to the terms of the Plan are not considered claims. Nor is a request for a det ermination of whether an individual is eligible for benefits under the Plan considered to be a claim. However, if a claimant files a claim for specific benefits and the claim is denied because the individual is not eligible for benefits under the Plan, the coverage determination is consi dered a claim. A request for prior approval of a benefit that does not require prior approval by the Plan is not considered a claim. However, requests for prior approval of a benefit where the Plan does require prior approva l (e.g., hospital pre - admission certification, etc.) are considered claims and should be submitted as pre - service claims (or urgent claims, if applicable), as described in the following procedures.