Continuation coverage

If ComPsych determines that you need urgent care, ComPsych will provide telephonic crisis counseling and make an appropriate referral to your benefit plan and/or emergency resources in the community. The EAP does not provide urgent care.

Because ComPsych pays all EAP providers directly, you should not make any payment to a provider for EAP services. In the event that you mistakenly pay a provider for EAP services, ComPsych will make a determination on your request for reimbursement within 15 days after receipt of the Claim (if EAP services have not yet been received) or with 30 days after receipt of the Claim (if the EAP services have already been received). ComPsych will notify you of its determination in writing, within the 15 day or 30 day period, as applicable.

To use EAP, call ComPsych at 888-226-1420. You do not pay for or file claim forms for your EAP counseling sessions. If you require additional services beyond that provided by EAP, those services may be provided under your medical plan.

If you have a problem with a plan benefit, contact ComPsych. The Care Manager is responsible for determining and informing you of your entitlement to a benefit.

The following categories of claims for benefits apply to the ExxonMobil Employee Assistance Program, and according to the type of claim submitted, ComPsych will review your claim and respond within a designated response time. If ComPsych needs additional time (an extension) to decide on your claim because of special circumstances, you will be notified within the claim response period.

Urgent care means care needed to avoid serious jeopardy to your life or health or to regain maximum function (or required to avoid severe pain), as determined by ComPsych or your treating physician. ComPsych does not make Claim determinations relating to urgent care.

Pre-service claims are any claims for benefits where the Plan provisions require approval before care is obtained.

Post-service claims are claims made after care is received and apply to claims under the ExxonMobil Employee Assistance Program.

Type of Claim	Response Time	Extension
Urgent care claims	Not applicable
Pre-service claims	15 days	An additional 15 days. However, if an extension is necessary due to incomplete information, you must provide the additional information within 45 days from the date of receipt of the extension notice.
Post-service claims	30 days	An additional 15 days. However, if an extension is necessary due to incomplete information, you must provide the additional information within 45 days from the date of receipt of the extension notice.

Denied claims

If your claim for benefits is denied completely or partially, and you authorize written communication to you, ComPsych will provide written notice to you, your beneficiary, or designated representative. The notice will describe:

• The specific reason(s) for the denial for the denial decision,
• Identify Plan provisions on which the decision is based,
• Describe any additional material or information necessary for an appeal review and an explanation of why it is necessary,
• Explain the review procedure, including time limits for appealing the decision and to sue in federal court,
• Identify your right to receive, free of charge, upon your request, any internal rule, guidelines, protocol, or similar criterion relied on in making the decision, and
• Identify your right to receive, free of charge, upon your request, an explanation of the clinical judgment on which the decision is based (if the denial is based on exclusion of experimental treatment services or because EAP services are not clinically appropriate).

If you do not authorize written notice, ComPsych will furnish this information to you or your Authorized Representative by telephone.

Filing a mandatory appeal

If you believe your Claim for EAP benefits was denied in error, you may appeal the decision. Your appeal must be submitted in writing to ComPsych within 180 days following your receipt of a denial notice. 

Your appeal should state the reasons why you feel your Claim for EAP benefits is valid and include any additional documentation that you feel supports your Claim for EAP benefits. You can also include any additional questions or comments. You may submit written comments, documents, records and other information relating to your appeal, whether or not the comments, documents, records or information were submitted in connection with the initial Claim for EAP benefits. On your request, ComPsych will make relevant documents available to you. 

The review of the initial decision will consider all new information, whether or not it was presented or available for the initial decision. The person who conducts the appeal review will be different from the person(s) who originally denied your Claim for EAP benefits and will not report directly to the original decision maker or prior reviewer. 

You or your Authorized Representative will be notified of the appeal decision within the following time frames:

• If the case involves an adverse determination on a request for EAP services or a pre-service adverse determination relating to reimbursement, within thirty (30) days of ComPsych's receipt of the request for appeal;
• If the case involves a post-service adverse determination relating to reimbursement, within sixty (60) days of ComPsych's receipt of the request for appeal.

If ComPsych needs additional time to decide on your claim because of special circumstances, you will be notified within the claim response period. However, an extension may be requested, but the law stipulates that no additional time will be allowed.

If you authorize written communication, ComPsych will give you or your Authorized Representative the decision on the appeal in writing. If the denial is upheld on appeal, the notice will set forth:

• The specific reason(s) for the denial and the Plan provisions upon which the denial is based.
• A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim.
• Notice of your right to receive, free of charge, upon your request, any internal rule, guidelines, protocol, or similar criterion relied on in making the decision.
• Notice of your right to receive, free of charge, upon your request, an explanation of the clinical judgment on which the decision is based (if the denial is based on exclusion of experimental treatment services or because EAP services are not clinically appropriate).
• A statement of your right to bring an action under section 502(a) of the Employee Retirement Income Security Act (ERISA).

If you do not authorize written notification, ComPsych will furnish this information to you or your Authorized Representative by telephone. If you do not agree with the final decision of ComPsych, you may bring a lawsuit in federal district court within one year of the final decision. You cannot bring legal action unless your Claim has been reviewed and denied by ComPsych.

Legal actions

No action at law or in equity to recover benefits under the Plan shall be brought unless the mandatory appeal process has been completed. In any event, no such action shall be brought after the expiration of one year from the time an appeal is decided by ComPsych.