94 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 authorized 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 determination 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 considered 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 approval (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. Types of Claims Health benefit claims can be filed for medical, mental health, substance use disorder, and prescription drug, benefits. There are four categories of health claims as described below: Pre-Service Claim means a claim for a benefit for which the Plan requires approval before health care is obtained, or approval is required in order to receive the maximum benefit provided by the Plan. Urgent Claim means a claim for health care or treatment that if normal pre-service standards were applied, would seriously jeopardize the life or health of the Covered Person or the ability of the Covered Person to regain maximum function or, in the opinion of a physician with knowledge of the covered person’s medical condition, subject the covered person to severe pain that could not be adequately managed without the care or treatment that is the subject of the claim. However, the Plan will not deny benefits for these procedures or services if it is not possible for the claimant to obtain the pre-approval, or the pre-approval process would jeopardize the claimant’s life or health. Concurrent Claim means a claim that is reconsidered after an initial approval is made, resulting in a reduction, termination or extension of a benefit. (An example of this type of claim would be an inpatient hospital stay originally certified for five days that is reviewed at three days to determine if the full five calendar days stay is still appropriate. In this situation, a decision to reduce, terminate or extend the hospital stay is made concurrently with the period of hospitalization.) Post-Service Claim means a claim for benefits that is not a pre-service, concurrent or urgent claim. Specifically, a claim submitted for payment after health services or treatment have been obtained. Claim Elements A claim must include the following elements to trigger the Plan’s internal claims process: • Be written or electronically submitted (oral communication is acceptable for authorization of services only for Urgent Care Claims); • Be received by the Plan Administrator or Claims Administrator (as applicable);