• Date of onset of the illness or injury • Diagnosis or ICD code • Procedure code (CPT, ADA, or HCPCS) • Dates of service and itemized charges for each service rendered • If the services rendered are for treatment of an accidental injury, you must also send us the date, time, location, and brief description of the accident. Claim Filing Deadlines As soon as Medicare has processed your claim, please submit it to us in the manner stated above. We must receive your claim: • Within 365 days of the date of hospital or skilled nursing facility discharge for inpatient expenses, or within 365 days of the date on which noninpatient expenses were incurred; or • Within 90 days of the date you receive the Medicare Summary Notice. The plan will not provide benefits for claims we receive after the later of these two dates. The plan will also not provide benefits for claims which were denied by Medicare because they were received past Medicare's submission deadline. Claims Payment Payment for benefits provided under this plan for covered services or supplies will be made, as prescribed by law, to you, the provider of services or supplies, or jointly to you and the health care provider. Providers who are participating with Medicare will be paid directly. Payment of benefits in this manner, in good faith, shall discharge our obligation to the extent of the payment amount, so that we will not be liable to anyone aggrieved by the selection of payee. We make every effort to process your claims as quickly as possible. We will tell you if this plan won’t cover all or part of the claim no later than 30 days after we first receive the claim. This notice will be in writing. We can extend the time limit by up to 15 days if it’s decided that more time is needed due to matters beyond our control. We will let you know before the 30-day time limit ends if we need more time. If we need more information from you or your health care provider in order to decide your claim, we’ll ask for it in our notice and allow you or your health care provider at least 45 days to send us the information. In such cases, the time it takes to get the information to us doesn’t count toward the decision deadline. Once we receive the information we need, we have 15 days to give you our decision. If your claim was denied, in whole or in part, our written notice will include: • The reasons for the denial and a reference to the provisions of this plan on which it was based • A description of any additional information needed to reconsider the claim and why that information is needed • A statement that you have the right to appeal our decision • A description of the plan's complaint and appeal processes If there were clinical reasons for the denial, you’ll receive a letter stating these reasons. 10 Group Plan G/Age