Plan participants who contact RTO/ERO after a claim has been denied will be directed to a claims specialist from Johnson Inc. to discuss the rationale of the decision. If the participant is not in agreement with the reason from Johnson Inc. and contacts RTO/ERO again, the participant will receive an application letter from RTO/ERO.
This letter will describe the process and contain a form that the plan participant must complete and submit to RTO/ERO in order for the claim to be reviewed. The plan participant would be required to specifically indicate that their claim should be approved based upon the fact that at least one of the three criteria is applicable. Forms are returned when they do not clearly identify at least one of the three criteria.
Upon receiving the form and any other pertinent information from the member, RTO/ERO will keep a copy and send the originals to Johnson Inc. Subsequently, Johnson Inc. will do an independent review of the claim. The adjudication of the benefit entitlement will be measured against the three criteria. Johnson Inc. will notify the member if the denial was upheld or overturned.
Johnson Inc. would report the individual reviews and outcomes to each HSIC meeting. If the HSIC determines that a review was not handled as it should have been and that any of the three criteria applied, then HSIC would provide Johnson Inc. with the direction, which would apply to all future claims.