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 found in the Key Terms section of 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.

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.

Grievances

Quality of care or operational issues arise if you are dissatisfied with the service received from Aetna or want to complain about a participating provider. To make a complaint about a quality of care or operational issue (called a grievance), call or write to Member Services within 30 days of the incident. Include a detailed description of the matter and include copies of any records or documents that you think are relevant to the matter. Aetna will review the information and provide you with a written decision within 30 calendar days of the receipt of the grievance, unless additional information is needed, but cannot be obtained within this time frame. The notice of the decision will specify what you need to do to seek an additional review.

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 for appeal must be made 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 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
• You have exhausted the applicable appeal process.

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.

Claims fiduciary

For the purpose of section 503 of Title 1 of the Employee Retirement Income Security Act of 1974, as amended (ERISA), the claims fiduciary is the person with complete authority to review all denied claims for benefits under the Plan. The claims fiduciary is Aetna for both medical Level One and Level Two and voluntary 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 Level One, Level Two, and Voluntary Appeals:	Mandatory and Voluntary Mental Health and Substance Abuse Appeals:	Prescription Drug Mandatory and Voluntary Appeals:	Eligibility Appeals
Aetna PO 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. 800-946-3979	Administrator-Benefits ExxonMobil Medical Plan P.O. Box 18025 Norfolk, VA 23501-1867

This includes, but is not limited to, determining whether hospital or medical treatment is, or is not, medically necessary. In exercising its fiduciary responsibility, each claims fiduciary has discretionary authority on appeal to:

• Determine whether, and to what extent, you and your covered family members are entitled to benefits, and
• Construe any disputed or doubtful terms of the Plan.

Each claims fiduciary has the right to adopt reasonable policies, procedures, rules and interpretations of the Plan to promote orderly and efficient administration. A claims fiduciary may not act arbitrarily and capriciously, which would be an abuse of its discretionary authority.

The EMRMP is responsible for making reports and disclosures required by ERISA, including the creation, distribution and final content of:

• Summary Plan Descriptions,
• Summary of Material Modifications, and
• Summary Annual Reports.

Member Services

Member Services information for the Retiree Medical Plan - Aetna Select option

Member Services department

Health Concierges (HCs) (customer service representatives ) are trained to answer your questions and to assist you in using the Plan properly and efficiently.

Call the Member Services toll-free number on your ID card to:

• Ask questions about benefits, referrals and coverage,
• Change your PCP, or
• Notify Aetna about an emergency.

Please call your PCP’s office directly with questions about appointments, hours of service, referrals or medical matters.

Also, you must notify the Benefits Service Center of changes that might affect your eligibility and enrollment status, such as changes in your name or telephone number.

Internet access

You can access Aetna on the internet at www.aetna.com to conduct business with the Member Services department electronically.

When you visit the Member Services site, you can:

• Find answers to common questions,
• Change your PCP,
• Order a new ID card, or
• Contact the Member Services department with questions.

Please be sure to include your ID number and e-mail address.

Rights and responsibilities

Rights and responsibilities on the Retiree Medical Plan - Aetna Select Option

Your rights and responsibilities

As a plan participant, you have a right to:

• Get up-to-date information about the doctors and hospitals participating in the Plan.
• Obtain primary and preventive care from the PCP you chose from the Plan’s network.
• Change your PCP to another available PCP who participates in the Aetna network.
• Obtain covered care from participating specialists, hospitals and other providers.
• Be referred to participating specialists who are experienced in treating your chronic illness.
• Be told by your doctors how to make appointments and get health care during and after office hours.
• Be told how to get in touch with your PCP or a back-up doctor 24 hours a day, every day.
• Call 911 (or any available area emergency response service) or go to the nearest emergency facility in a situation that might be life-threatening.
• Be treated with respect for your privacy and dignity.
• Have your medical records kept private, except when required by law or contract, or with your approval.
• Help your doctor make decisions about your health care.
• Discuss with your doctor your condition and all care alternatives, including potential risks and benefits, even if a care option is not covered.
• Know that your doctor cannot be penalized for filing a complaint or appeal.
• Know how the Plan decides what services are covered.
• Know how your doctors are compensated for the services they provide. If you would like more information about Aetna’s physician compensation arrangements, visit their website at www.aetna.com. Select DocFind from the drop-down menu under Quick Tools, then under How do I learn more about, select the type of plan you’re enrolled in.
• Get up-to-date information about the services covered by the Plan — for instance, what is and is not covered and any applicable limitations or exclusions.
• Get information about copayments and fees you must pay.
• Be told how to file a complaint, grievance or appeal with the Plan.
• Receive a prompt reply when you ask the Plan questions or request information.
• Obtain your doctor’s help in decisions about the need for services and in the grievance process.
• Suggest changes in the Plan’s policies and services.

As a plan participant, you have a right to:

• Choose a PCP from the Plan’s network and form an ongoing patient-doctor relationship.
• Help your doctor make decisions about your health care.
• Tell your PCP if you do not understand the treatment you receive and ask if you do not understand how to care for your illness.
• Follow the directions and advice you and your doctors have agreed upon.
• Tell your doctor promptly when you have unexpected problems or symptoms.
• Consult with your PCP for non-emergency referrals to specialist or hospital care.
• See the specialists your PCP refers you to.
• Make sure you have the appropriate authorization for certain services, including inpatient hospitalization and out-of-network treatment.
• Call your PCP before getting care at an emergency facility, unless a delay would be detrimental to your health.
• Understand that participating doctors and other health care providers who care for you are not employees of Aetna and that Aetna does not control them.
• Show your ID card to providers before getting care from them.
• Pay the copayments required by the Plan.
• Call Member Services if you do not understand how to use your benefits.
• Promptly follow the Plan’s grievance procedures if you believe you need to submit a grievance.
• Give correct and complete information to doctors and other health care providers who care for you.
• Treat doctors and all providers, their staff, and the staff of the Plan with respect.
• Advise Aetna about other medical coverage you or your family members may have. Not be involved in dishonest activity directed to the Plan or any provider. Read and understand your Plan and benefits. Know the copayments and what services are covered and what services are not covered.