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Collects account holder identity and contact details, spending account information, and service and claim details including claim number, claim type (FSA/Dep Care), submitted amount, and disputed amount. Includes a written explanation space and requires attaching the Explanation of Processing Report and relevant supporting documents. 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Included names and dates when possible. You may attach a separate sheet if necessary.\u003Cbr> |  |  |  |  |  |  |  |  |  |  |  |\n| Authorization |  |  |  |  |  |  |  |  |  |  |  |\n| I hereby authorize Further to conduct an internal review of the situation described above.\u003Cbr>Account Holder Signature Date |  |  |  |  |  |  |  |  |  |  |  |\n\n\n| Appeal Procedures |\n| --- |\n| You may appeal a denial or partial denial of your claim by following our appeal procedures. The following is a general outline of the appeal process. For specific details regarding the appeal process, please refer to your Summary Plan Description.\u003Cbr>Level One Appeal Process:\u003Cbr>1. Complete the Appeal form.\u003Cbr>To designate someone to act on your behalf complete an Authorization for Release of Information form. To obtain an Authorization for Release of Information form or to receive assistance in completing the form, please contact our customer service department at 1-866-758-6119.\u003Cbr>2. Attach any documents, records, or other information that relates to the appeal.\u003Cbr>3. Fax the completed Appeal form and any additional information to (866) 231-0214 or mail to:\u003Cbr>Further c/o CareFirst\u003Cbr>Attention: Appeals\u003Cbr>PO Box 14836\u003Cbr>Lexington, KY 40511\u003Cbr>A full and fair review of your appeal will be provided and a notice of the determination will be provided in writing and mailed to you within 30 days.\u003Cbr>*PLEASE NOTE: You have until the later of your plan’s run out end date or 180 days from the date of your receipt of the adverse determination of the claim to file an appeal. If you have terminated employment during the year or if you are unsure of your plan’s run out end date please contact your group representative or our customer service department.\u003Cbr>Level Two Appeal Process:\u003Cbr>Please refer to your Summary Plan Description for information on your additional appeal rights. If your Plan requires second level appeal rights directly to Further follow these instructions to file a second level appeal.\u003Cbr>1. Complete the Level One Appeal process.\u003Cbr>2. Within 30 days of the receipt of Further’s initial appeal determination, or the later of your run out end date, send a written request to our Further Corporate Appeals Committee to reconsider the decision.\u003Cbr>3. Attach any new additional documentation you would like considered.\u003Cbr>4. Fax the letter and additional information to (866) 231-0214 or mail to:\u003Cbr>Further c/o CareFirst\u003Cbr>Attention: Appeals\u003Cbr>PO Box 14836\u003Cbr>Lexington, KY 40511\u003Cbr>A written notification of the Committee’s decision about your appeal will be sent within 30 days from the date your request is received. |\n\nX22021R02 (08/22)","cbCaifsRiTNMbOVh","https://ap.wps.com/l/cbCaifsRiTNMbOVh","pdf",108667,"English","# Account Holder Information\n# Service Information\n# Authorization\n# Appeal Procedures\n## Level One Appeal Process\n## Level Two Appeal Process","[{\"question\":\"What information is required from the account holder?\",\"answer\":\"The form requires the account holder’s last name, first name, middle initial, street address, city/state/zip, email address, employer name, daytime phone number, spending account ID, and relationship to the member.\"},{\"question\":\"What documents must be attached to support the appeal?\",\"answer\":\"Attach a copy of the Explanation of Processing Report related to the denial and include any documents, records, or other information that relates to the appeal.\"},{\"question\":\"How long does the account holder have to file an appeal?\",\"answer\":\"File an appeal by the later of the plan’s run out end date or 180 days from the date of receipt of the adverse claim determination.\"}]","CareFirst Appeal Form - X22021R02 | PDF",1789633525]