For most of your network claims for benefits, you do not need to submit a claim. This will be done automatically for you by the network provider. However for some network providers and out of network providers you will be required to file a claim for benefits.

All claims and appeals for benefits should be directed to the appropriate Claims fiduciary. Plan eligibility is determined by the Administrator-Benefits. The Administrator-Benefits determination of eligibility is final and no appeals are available.

How to file a Claim for benefits

If your providers do not file claims for benefits for you, follow the instructions on the claim forms, which are available at the Healthcare forms and useful links section ExxonMobil Family Internet site.

If you need to file a claim:

• Submit a completed claim form with necessary documentation within 12 months from the date the expense was incurred.
• Aetna will send you an explanation of benefits (EOB) for each claim. The EOB shows what service was performed, how much the provider charged, and what the covered charge was under the Plan. It shows if a deductible or copayment was involved, as well as the calculation used to determine your benefit.
• Keep the explanation of benefits for your records.
• You can review your EOB by going to Aetna’s website at www.aetna.com and following the instructions.

For prescription drug claims, refer to a href="https://www.exxonmobilfamily.com/en/health/pos-ii-a-and-b/key-terms#Short-term%20prescriptions" target="_self">Short-term prescriptions in the Prescription Drug Program section.

Effective January 1, 2023, non-emergent care outside the U.S. will no longer be covered. If you paid for medical care received when traveling or working outside the United States prior to January 1, 2023, you have up to 12 months to request reimbursement by submitting an itemized bill along with a claim form. If the original bills are in a foreign language or paid in a foreign currency, you should obtain an English translation, if possible, of the services rendered and the claims administrator will convert the bill to U.S. dollars as of the date of service. Covered expenses are payable at an out-of-network schedule. 

Initial Claim Review and Decision

When you file a claim, the claims administrator reviews the claim and makes a decision to either approve or deny the claim (in whole or in part). You will receive a written notice of the claim decision within the time limits described in the chart that follows. Those time limits are based on the type of claim and whether you submit a proper claim, including all necessary information.

Urgent, Pre-Service and Post-Service claims

Time limits
Urgent care claim	Pre-service claim		Post-service claim
If the initial claim is properly completed:
Notice will be given to you not later than 72 hours after receiving the initial claim.         Notice of initial benefits decision 24 hours in the case of a concurrent claim, if you request to extend the authorized treatment at least 24 hours before the existing authorization ends	Notice will be given to you not later than 15 days after receiving the initial claim, unless an extension, up to 15 days, is necessary due to matters beyond the control of the plan. You will be notified within the initial 15 days if an extension is needed. In the case of a concurrent claim, you will be notified in advance of any reduction or termination of treatment so you may appeal the decision		Notice will be given to you not later than 30 days after receiving the initial claim, unless an extension, up to 15 days, is necessary due to matters beyond the control of the plan. You will be notified within the initial 30 days if an extension is needed. In the case of a concurrent claim, you will be notified in advance of any reduction or termination of treatment so you may appeal the decision
If the initial claim is not properly completed:
Notice will be given to you as soon as possible (but no more than 24 hours after Aetna receives the claim). You will have up to 48 hours to provide the additional information.	Notice will be given to you 15 days of receipt of the claim.   You will have up to 45 days to provide the additional information.		Notice will be given to you 30 days of receipt of the claim.   You will have up to 45 days to provide the additional information.
If additional information is required:
The Plan´s benefit determination will be given to you not later than 48 hours after receiving additional information or upon the expiration of your 48-hour deadline to provide such information to complete the claim, whichever is earlier.		The Plan´s benefit determination will be given to you not later than 15 days after receiving your additional information or upon the expiration of your 45-day deadline to complete the claim, whichever is earlier.

 

Claim denial and reconsideration

If all or part of a claim is denied, Aetna Member Services will provide you with a written explanation supporting the denial and describing additional information, if any, that may improve the claim’s likelihood of being approved.

For Concurrent Care Claims Aetna will send you written notification of an affirmative benefit determination. For other types of claims, you may only receive notice if Aetna makes an adverse benefit determination.

Adverse benefit determinations are decisions Aetna makes that result in denial, reduction, or termination of a benefit or the amount paid for it. It also means a decision not to provide a benefit or service.

Adverse benefit determinations can be made for one or more of the following reasons:

• The individual is not eligible to participate in the Plan, or
• Aetna determines that a benefit or service is not covered by the Plan because:

• it is not included in the list of covered benefits,
• it is specifically excluded,
• a Plan limitation has been reached, or
• it is not medically necessary.

How to appeal an Adverse Benefit Determination

Aetna will send you a written notice of an adverse benefit determination that will include the reason for the decision and will explain what steps you must take if you wish to appeal. The Plan provides for two levels of appeal plus an option to seek External Review of the adverse benefit determination. Appeals should be filed within 180 days from the date of the notice of Adverse Benefit Determination.

The following chart summarizes some information about how level one and level two appeals are handled for different types of claims. In certain situations, the time frames shown may be extended. 

Type of Claim	Level One Appeal	Level Two Appeal
Urgent care claim:a claim for medical care or treatment where delay could: Seriously jeopardize your life or health, or your ability to regain maximum function, or Subject you to severe pain that cannot be adequately managed without the requested care or treatment	36 hours Review provided by Aetna personnel not involved in making the adverse benefit determination.	36 hours Review provided by Appeals Committee.
Pre-service claim:a claim for a benefit that requires Aetna’s approval of the benefit in advance of obtaining medical care.	15 calendar days Review provided by Aetna personnel not involved in making the adverse benefit determination	15 calendar days Review provided by Appeals Committee.
Concurrent care claim extension:a request to extend a previously approved course of treatment.	Treated like an urgent care claim or a pre-service claim depending on the circumstances	Treated like an urgent care claim or a pre-service claim depending on the circumstances
Post-service claim:a claim for a benefit that is not a pre-service claim.	30 calendar days Review provided by Aetna personnel not involved in making the adverse benefit determination.	30 calendar days Review provided by Appeals Committee.

External review of Aetna’s final appeal determinations

The external review process is expanded to apply with respect to any adverse determination by a plan or issuer under the CAA, including grandfathered plans, and with respect to any item or service to which the No Surprises Act applies.

 If the Level One and Level Two appeals uphold the original adverse benefit determination, you may have the right to pursue an external review of your claim.

An external review is a review by an independent physician, with appropriate expertise in the area at issue, of claim denials and denials based upon lack of medical necessity, a rescission of coverage, or an adverse determination for surprise bills (medical and air ambulance bills, including a determination of whether an adverse determination is subject to surprise billing provisions) or the experimental or investigational nature of a proposed service or treatment. You may request a review by an external review organization (ERO) if

• You have received notice of the denial of a claim by Aetna, and
• Your claim was denied because Aetna determined that the care was not medically necessary or was experimental or investigational, and

You must submit the Request for External Review Form to Aetna within four months of the date you received the final claim denial letter. The form must be accompanied by a copy of the final claim denial letter and all other pertinent information that supports your request.

Aetna will contact the External Review Organization that will conduct the review of your claim. The External Review Organization will select an independent physician with appropriate expertise to perform the review. In rendering a decision, the external reviewer may consider any appropriate credible information submitted by you with the Request for External Review Form, and will follow the applicable plan’s contractual documents and plan criteria governing the benefits. You will generally be notified of the decision of the External Review Organization within 45 days of Aetna’s receipt of your request form and all necessary information. An expedited review is available if your physician certifies (by telephone or on a separate Request for External Review Form) that a delay in receiving the service would jeopardize your health. Expedited reviews are decided within 3-5 calendar days after Aetna receives the request.

You are responsible for the cost of compiling and sending the information that you wish to be reviewed by the External Review Organization to Aetna. Aetna is responsible for the cost of sending this information to the External Review Organization.

Nonalienation of Benefits

No benefit, right or interest of any Covered Person under the Plan shall be subject to anticipation, alienation, sale, transfer, assignment, pledge, encumbrance, charge, garnishment, execution or levy of any kind, either voluntary or involuntary, including any liability for, or subject to, the debts, liabilities or other obligations of such person; and any attempt to anticipate, alienate, sell, transfer, assign, pledge, encumber, charge, garnish, execute or levy upon, or otherwise dispose of any right to benefits payable hereunder or legal causes of action, shall be void.  Notwithstanding the foregoing, the Plan may choose to remit payments directly to health care providers with respect to covered services, if authorized by the Covered Person, but only as a convenience to Covered Persons.  Health care providers are not, and shall not be construed as, either “participants” or “beneficiaries” under this Plan and have no rights to receive benefits from the Plan or to pursue legal causes of action on behalf of (or in place of) Covered Persons under any circumstances.

Uncashed Checks 

If a check to a Participant for benefits under the Plan remains uncashed for 5 years after issue, amounts attributable to such check shall remain in the Plan until the time the participant has requested these funds

The provision in this SPD is deemed to be notice to any and all individuals to whom notice may be required, and no additional notice of the above provisions is needed for a provider or otherwise.