Filing a claim

A claim occurs whenever a plan participant requests:

• An authorization or referral from a participating provider or Aetna, or
• Payment for items or services received.

You do not need to submit a claim for most of your covered healthcare expenses. However, if you receive a bill for covered services, the bill must be submitted promptly to Aetna for payment. Send the itemized bill for payment with your identification number clearly marked to the address shown on your ID card.

You must submit a claim form within two calendar years from the date of a service.

Aetna will make a decision on your claim using coverage policies and the definitions included in this document. 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.

Aetna will provide you with written notices of adverse benefit determinations within the time frames shown below. These time frames may be extended under certain limited circumstances. The notice you receive from Aetna will provide important information that will assist you in making an appeal of the adverse benefit determination, if you wish to do so. Please see Complaints and Appeals for more information about appeals.

A claim must be filed in writing to the appropriate claims administrator:

• Aetna Member Services for medical, mental health and substance abuse-related claims, or
• Express Scripts for non-network and coordination of benefit prescription drug claims.

Type of Claim	Response time
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	As soon as possible but not later than 72 hours.
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
Concurrent care claim extension: a request to extend a previously approved course of treatment.	Urgent care claim - as soon as possible, but not later than 24 hours, provided the request was received at least 24 hours prior to the expiration of the approved treatment. Other claims - 15 calendar days
Concurrent care claim reduction or termination: a decision to reduce or terminate a course of treatment that was previously approved.	With enough advance notice to allow the plan participant to appeal.
Post-service claim: a claim for a benefit that is not a pre-service claim.	30 calendar days

Extensions of time frames

The time periods described in the chart may be extended.

For urgent care claims: If Aetna does not have sufficient information to decide the claim, you will be notified as soon as possible (but no more than 24 hours after Aetna receives the claim) that additional information is needed. You will then have at least 48 hours to provide the information. A decision on your claim will be made within 48 hours after the additional information is provided.

For non-urgent pre-service and post service claims: The time frames may be extended for up to 15 additional days for reasons beyond the Plan’s control. In this case, Aetna will notify you of the extension before the original notification time period has ended. If you fail to provide the information, your claim will be denied.

If an extension is necessary because Aetna needs more information to process your post service claim, Aetna will notify you and give you an additional period of at least 45 days after receiving the notice to provide the information. Aetna will then inform you of the claim decision within 15 days after the additional period has ended (or within 15 days after Aetna receives the information, if earlier). If you fail to provide the information, your claim will be denied.

Grievances and appeals

There are procedures for you to follow if you are dissatisfied with a decision that Aetna has made or with the operation of the Plan. The process depends on the type of complaint you have. There are two categories of complaints:

• Quality of care or operational issues, and
• Adverse benefit determinations.

Complaints about quality of care or operational issues are called grievances. Complaints about adverse benefit determinations are called appeals.

Appeals of Adverse Benefit Determinations by Aetna

Aetna will send you written notice of an adverse benefit determination. The notice will give the reason for the decision and will explain what steps you must take if you wish to appeal. The notice will also tell you about your rights to receive additional information that may be relevant to the appeal. Requests should be presented within 180 days from the date of the notice.

The Plan provides for two levels of appeal plus an option to seek External Review of the adverse benefit determination. You must complete the two levels of appeal before bringing a lawsuit. The following chart summarizes some information about how 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.

Effective January 1^st, 2021, you may perform your appeal in writing or verbally. You may also choose to have another person (an authorized representative) make the appeal on your behalf by providing written consent to Aetna. However, in case of an urgent care claim or a pre-service claim, a physician familiar with the case may represent you in the appeal.

Depending on the type of appeal, you and/or an authorized representative may attend the Level 2 appeal hearing and question the representative of Aetna and any other witnesses, and present your case. The hearing will be informal. You may bring your physician or other experts to testify. Aetna also has the right to present witnesses.

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. See External review of Aetna’s final appeal determinations for more information.

External review of Aetna’s final appeal determinations

You may file a voluntary appeal for external review of any final appeal determination that qualifies.

You must complete the two levels of appeal described above before you can appeal for external review. Subject to verification procedures that may be established, your authorized representative may act on your behalf in filing and pursuing this voluntary appeal. You must request this voluntary level of review within 60 days after you receive the final denial notice.

If you file a voluntary appeal, any applicable statute of limitations will be tolled while the appeal is pending. The filing of a claim will have no effect on your rights to any other benefits under the Plan. However, the appeal is voluntary and you are not required to undertake it before pursuing legal action.

If you choose not to file for voluntary review, the Plan will not assume that you have failed to exhaust your administrative remedies because of that choice.

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, 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

The claim denial letter you receive from Aetna will describe the process to follow if you wish to pursue an external review, and will include a copy of the Request for External Review Form.

You must submit the Request for External Review Form to Aetna within 60 calendar days 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.

No Assignment

The rights or benefits under this Plan may not be assigned by a participant or beneficiary. Any assignment will be treated as a direction to pay benefits to an assignee rather than as an assignment of rights.

Limited Authorization of Payments

To the extent allowed by the claims administrator, you may authorize your claims administrator to make payments directly to a health care provider for covered services. Further, even without such authorization, a claims administrator may make direct payments to a health care provider for covered services according to the claims administrator’s rules and procedures at the applicable time.

Authorization of payments to a health care provider or direct payments to a health care provider are not assignment of benefits. Even though you may authorize a health care provider to receive a payment or reimbursement of covered services and even though a claims administrator may pay a health care provider directly for payments or reimbursements of covered services, in no event will any such authorizations, payments or reimbursements to or on behalf of a health care provider cause the provider to become a plan participant or plan beneficiary (or assignee of a participant or beneficiary) under ERISA.

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.

No Assignment of Rights and Benefits

Your rights and benefits under a medical option cannot be assigned, sold or transferred to any person, including your health care provider. For this purpose, your plan rights and benefits include, without limitation, the right to file an administrative appeal (internal and external), the right to sue following a denied administrative appeal and any other plan rights and benefits, whether actual or potential. Any purported assignments of rights and/or benefits under the Plan will be void and will not apply to the Plan. Further, a payment or reimbursement of covered services by a claims administrator to a health care provider will not waive the application of this provision. The application of this provision does not affect your right to appoint an authorized representative.

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.

Health Care Provider Agreements Not Binding on the Plan

Sometimes your health care provider requests that you sign various agreements and other documentation as a condition of receiving health care services from the provider. Any agreement, assignment or other document executed by you and a health care provider (or executed by parties that include you and a health care provider but that do not include the plan administrator) are not binding on and will have no legal effect whatsoever on the Plan or any claims administrator. Further, a payment or reimbursement of covered services by a claims administrator to a health care provider (whether pursuant to an authorization or otherwise) will not waive the application of this provision.

Recovery of Excess Payments

Whenever payments have been made in excess of the amount necessary to satisfy the provisions of this plan, the Plan has the right to recover these excess payments from any individual (including you, your family members and a provider), insurance company or other entity or organization to whom the excess payments were made—or to withhold payment, if necessary, on future benefits until the overpayment is recovered. Whenever payments have been made based on inaccurate, misleading or fraudulent information provided by you or your family member, the Plan will exercise all available legal rights to recover the overpayment, including its right to withhold payment on future benefits or offset future benefits to the extent of the overpayment until the overpayment is recovered.

Claims fiduciary

The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is Aetna for medical mandatory appeals, Magellan for mandatory and voluntary appeals for all mental health and substance abuse appeals, and Express Scripts for all prescription drug mandatory and voluntary appeals. You may contact the claims fiduciary as follows:

Medical Mandatory and Voluntary Appeals:	Mandatory and Voluntary Mental Health and Substance Abuse Related Appeals:	Prescription Drug Mandatory and Voluntary Appeals:	Eligibility Appeals
Aetna P. O. Box 14463 Lexington KY 40512	Magellan Healthcare P.O. Box 2128 Maryland Heights, Missouri, 63043	Express Scripts P.O. Box 66587 St. Louis, MO 63166-6587 Attn: Administrative Appeals Dept.	Administrator-Benefits ExxonMobil Medical Plan P.O. Box 64111 Spring, TX 77387-4111

Note: For initial claims incurred before January 1, 2021, the Administrator-Benefits is the claims fiduciary for medical voluntary appeals.

Administrator-Benefits
ExxonMobil Medical Plan
P.O. Box 64111
Spring, TX 77387-4111

The Administrator-Benefits determination of eligibility is final and no mandatory or voluntary appeals are available, including decisions regarding whether a child age 26 or older meets the clinical definition of totally and continuously disabled. All decisions by Magellan or Aetna confirming a dependent no longer meets the clinical definition of totally and continuously disabled are final.