92 Claims Filing and Appeal Procedures This Section of the SPD describes the procedures for filing claims and benefits as provided under the terms of the National IAM Benefit Trust Fund. It also describes the procedures for you to follow if your claim is denied in whole or in part and you wish to appeal the decision. The Plan’s internal claims and appeal procedures are designed to provide you with full, fair, and fast claim review and so that Plan provisions are applied consistently with respect to you and other similarly situated participants. In addition, the Plan must consult with a health care professional with appropriate training and experience when reviewing an adverse benefit determination that is based in whole or in part on a medical judgment (such as a determination that a service is not Medically Necessary or appropriate or is Experimental or Investigational). The internal claims process pertains to determinations made by the appropriate Claims Administrator about whether a request for benefits (known as a “claim”) is payable. If the appropriate Claims Administrator denies your claim for benefits (known as an “adverse benefit determination”), you have the right to appeal the denied claim under the Plan’s internal appeals process. For health benefits, you may be able to seek an external review with an Independent Review Organization (IRO) that conducts reviews of adverse benefit determinations either (i) after the Plan’s internal appeals process has been exhausted, or (ii) under limited circumstances before the Plan’s internal claims and appeals process have been exhausted. Appropriate Claims Administrator Types of Claims Processed CareFirst Administrators P.O. Box 14115 Lexington, KY 40512-4115 Phone: 1-866-871-0839 www.cfablue.com • Post-Service Medical Claims • First Level Appeals: • Pre-Service and Concurrent Care Medical Claims denied based on Medical Necessity • All Post-Service Medical Claims Quantum Health Appeals Department 5240 Blazer Parkway Dublin, OH 43017 1-800-257-2038 Fax: (877)-498-3681 www.quantum-health.com Pre-Service and Concurrent Care Medical Claims denied for reasons other than Medical Necessity CVS Caremark, Inc. 9501 East Shea Blvd. Scottsdale, AZ 85260-6719 Phone: 888-727-5575 www.cvscaremark.com • Prescription Drug Claims