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VISION SERVICE P.LAl'- CLAIMS APPEAL PROCEDURES COMPLAINTS - BENEFIT ELIGIBILITY l. If a claim for benefits is denied, Vision Service Plan will notify the claimant in writing of the specific reasons for the denial, including specific references to pertinent plan provisions. Vision Service Plan will also describe any additional materials or information necessary. 2. If the claimant, or the duly authorized representative, so requests within ninety (90) days of the date of receipt of written denial of the claim, the plan administrator, whose address is shown on the cover page of the Disclosure Form, through its designated representative will review the decision denying the claim. 3. The plan administrator will give the claimant a reasonable opportunity for a full and fair review of the decision denying the claim. The claimant will be given the opportunity to review pertinent documents, and to submit any statements, documents, or written arguments in support of this claim, and may, if so desired, appear personally at the Vision Service Plan office, 100 Howe Avenue, Sacramento, California 95825, to present the complaint to the Professional Relations Vice President. 4. If the claim is denied, the plan administrator will, within sixty (60) days after receipt of the request for review, advise the claimant in writing of the specific reasons for the decision, including specific references to the pertinent plan provisions on which a decision is based. COMPLAINTS - PROFESSIONAL SERVICES 1. The patient's written complaint will be referred to the Vision Service Plan's Professional Relations Vice President for his action. 2. The complaint will be evaluated and, if deemed appropriate, the original examining doctor will be contacted. 3. If the complaint can be resolved within fifteen (15) days, the disposition of the complaint will be forwarded to the complainant. Otherwise, a notíce of receipt of the complaint will be forwarded to the complainant advising the appropriate time for resolution. -14- 7/83 - .-.