97 • Federal taxpayer identification number (TIN) of the provider; • Billing name and address; and • If treatment is due to accident, accident details. Or • Attach all itemized bills or doctor’s statements that describe in full the services rendered. Warning: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit may be guilty of a crime and may be subject to fines and confinement in prison. Filing a Claim You may file claims for health benefits and appeal adverse claim decisions yourself or have an authorized representative do it for you. Often, the provider will make the claim on your behalf directly to the Claims Administrator. If your claim is denied, in whole or in part, you will receive a written notice of the denial from the Claims Administrator. The notice will explain the reason for the denial and the review procedures, including any applicable statute of limitation within which the claimant may file a claim in a court of law. 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. Urgent Care Claims If the Plan requires advance approval of a service, supply or procedure before a benefit will be payable, and if the Plan or your physician determines that it is an urgent care claim, you will be notified of the decision not later than 72 hours (shorter depending on medical urgency of the case) after the claim is received. The decision will be made by Quantum Health unless the decision relates to your eligibility to participate, in which case it will be made by the Fund Office, acting on behalf of the Board of Trustees. If there is not sufficient information to decide the claim, you will be notified of the information necessary to complete the claim as soon as possible, but not later than 24 hours after receipt of the claim. You will be given a reasonable additional amount of time, but not less than 48 hours, after the end of that additional time period (of after receipt of the information, if earlier). Other Health Claims (Pre-Service and Post-Service) If the Plan requires you to obtain advance approval of a service, supply or procedure before a benefit will be payable, a request for advance approval is considered a pre-service claim and should be filed with Quantum Health. You will be notified of the decision by Quantum Health not later than 15 calendar days after receipt of the pre-service claim. For other claims (post-service claims), you will be notified by CareFirst Administrators of the decision not later than 30 calendar days after receipt of the claim. For either a pre-service or a post-service claim, these time periods may be extended up to an additional 15 calendar days due to circumstances outside