One Chatham Center 112 Washington Place Pittsburgh, PA 15219   Explanation of Benefits (EOB) This is not a bill

This is not a bill. It explains payments made by UPMC Health Plan to health care providers for claims they submitted for health care services you recently received.

• Any additional payments that are your responsibility are listed.
• You can access our "Beginners's Guide to EOB's" on our website: www.upmchealthplan.com
• You can also register on our website to review claims, benefits, and copayment information at any time.

In some cases, services that you have received may NOT be covered, either because they are not part of your health benefits package or because you have exceeded the maximum allowable benefit for those services. A provider has the right to bill you for any portion of the submitted charges that has not been covered under your benefit plan.

One Chatham Center 112 Washington Place Pittsburgh, PA 15219   Explanation of Benefits (EOB) This is not a bill

Process to Request a Review of this Benefit Determination

If you disagree with the benefit determination that has been made by UPMC Health Plan for the claim(s) covered in this EOB, you may request that the decision be reviewed. UPMC Health Plan has established a two-level internal process to review all member complaints and grievances.

The complete description of the complaint and grievance process is in your UPMC Health Plan documents. A brief description of the process is listed below:

• A member or authorized representative has 180 days from the date of the EOB to file a complaint or grievance with UPMC Health Plan.

Initial Level Review:

• Contact Member Services or send a letter to file a complaint or grievance. When you contact Member Services by phone or send us a letter to file a complaint or grievance, UPMC Health Plan will send you a letter telling you that we have received your request. In the letter, we will also let you know that you may send us more information that may be helpful to us in making our decision about the claim(s) in question. We will also tell you about all of your rights under the law during the Initial Level Review.
• UPMC Health Plan will complete its review of the data and facts concerning the claim(s) in question within 30 days of the date we receive your request for review. We will send you a letter telling you of the Initial Review Committee decision. This letter will include the specific reasons for the decision and refer to the specific plan benefit or exclusion on which we made the decision. We will also tell you about the Second Level Review process and the time frame to request a review.

Second Level Review:

• You have 60 days from the date of the Initial Level Review decision letter to file a request for a Second Level Review. If you request a Second Level Review, UPMC Health Plan will send you a letter telling you of all your rights under the law during the Second Level Review. This includes your right to attend the Second Level Review Committee Meeting. We will let you know of the meeting 15 days before the Committee Meeting date.
• The entire Second Level review process will be completed within 30 days of when we receive your request for a Second Level Review. UPMC Health Plan will send you a letter telling you of the Second Level Review Committee decision. This letter will include the specific reasons for the decision and refer to the specific plan benefit or exception on which we made the decision. We will tell you about the process and time frame to appeal the decision made by UPMC Health Plan.

Following an adverse benefit determination at the Second Level Review, you have the right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA). You should contact your employer to obtain additional information concerning your rights under ERISA.

If you have any questions concerning the complaint and grievance process, please call the Member Services Department at 1-877-381-3764. TTY users should call 1-800-361-2629. Member Services staff are available to answer your calls Monday through Friday 8 a.m. to 8 p.m. and on Saturday from 8 a.m. to 3 p.m.