NOTICE OF CLAIMS PROCEDURES FOR PARTICIPANTS OF EMPLOYER SPONSORED GROUP HEALTH PLANS THAT ARE SUBJECT TO ERISA

The Employee Retirement Income Security Act or "ERISA" (29 U.S.C. §§ 1001 et seq.) governs certain employer group health plans. (Not all employer plans are subject to ERISA. Ask your employer if your benefit plan is subject to ERISA.) Under new ERISA regulations effective July 1, 2002, the following procedures will apply.

General Information on Requests for Authorization and Filing Claims

• All actions you may take may also be taken by your duly authorized representative ("Authorized Representative"), which may be your dental/vision care provider. HNDV may require evidence it deems reasonably necessary to verify any such representative.
• HNDV plan members are not required to file claims, except for services received from out-of-network/ non-participating providers.
• HNDV participating providers will receive payment for services provided to you in accordance with the terms of their agreement with HNDV.
• If you use a non-participating provider you may have to pay out-of-pocket for those services and file a claim with HNDV for reimbursement of the charges. If the services are approved, you will be reimbursed directly. To file a claim, you or your Authorized Representative must file a written claim on the appropriate form. For claims filing procedures, See "Notice of Claims" under MISCELLANEOUS PROVISIONS of your HNDV Evidence of Coverage/Certificate of Insurance.

Types of Claims or Requests for Authorization

The requirements for processing your claim or request depend on the type of claim or request submitted. A claim or request is defined by ERISA in one of the following categories: urgent, pre-service, post-service or concurrent.

Urgent

• A claim or request for service is considered "urgent" when a delay in the decision might pose an imminent and serious threat to your health, including but not limited to potential loss of life, limb, or major bodily function, or severe pain that cannot be managed without the care or treatment that is the subject of the claim.

• If a dental/vision care provider with knowledge of your medical condition determines that your claim or request is Urgent, HNDV will treat it as such.

Pre-Service

• A Pre-Service claim is a request for authorization of dental/vision care or treatment that you have not yet received, which is conditioned in whole or in part on HNDV's approval of coverage in advance of obtaining the dental/vision care.

Post-Service

• A Post-Service claim is a request for payment or reimbursement of costs for dental/vision care that has already been provided and which is not an Urgent Care claim.

Concurrent

• A concurrent request is a request for authorization of an extension or modification to an approved course of treatment that is already in progress.

Notice Of Determination

Note: HNDV reserves the right to extend the time periods specified below as allowed by law if such extension is necessary due to matters beyond the control of the Plan.

Urgent

For urgent requests, you will be notified regarding HNDV's decision as soon as possible but no later than 72 hours after its receipt of your request.

If you fail to provide HNDV with information sufficient to enable it to decide your claim or request for urgent care services, you will be notified of such failure as soon as possible, but not later than 24 hours after its receipt of the insufficient information. You will be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. After you provide the specified information, HNDV will provide you with its decision on your claim or request for urgent care servcies as soon as possible, but in no case later than 48 hours after the earlier of:

• HNDV's receipt of the specified information, or
• The end of the period afforded you to provide the specified additional information.

Pre-Service

For pre-service claims or requests, you will be notified regarding HNDV's decision as soon as possible but no later than 15 calendar days after its receipt of your request.

HNDV reserves the right to extend this 15-day period a single time for up to an additional 15 days if it determines that the extension is necessary due to matters beyond its control, and notifies you prior to the expiration of the initial 15-day period of the circumstances requiring the extension of the time and date by which it expects to render a decision.

If the extension described above is necessary because you failed to submit the information necessary to decide the claim or request, the notice of extension must describe specifically the required information. You shall be afforded at least 45 days from the receipt of such notice within which to provide the specified information.

Post-Service Claims

For post-service claims, you will be notified regarding HNDV's decision as soon as possible but no later than 30 calendar days after its receipt of your request.

HNDV reserves the right to extend this 30-day period a single time for up to an additional 15 days if it determines that the extension is necessary due to matters beyond its control, and notifies you prior to the expiration of the initial 30-day period, of the circumstances requiring the extension of the time and date by which it expects to render a decision.

If the extension described above is necessary because you failed to submit the information necessary to decide the claim, the notice of extension must describe specifically the required information. You shall be afforded at least 45 days from the receipt of such notice within which to provide the specified information.

Concurrent Care Decisions

If HNDV has approved an ongoing course of treatment to be provided to you over a period of time or a number of treatments, HNDV's reduction or termination of the course of treatment (other than by amendment or termination of your HNDV constitutes a denial of your claim).

In the event of such a denial, HNDV will notify you in sufficient time prior to the reduction or termination in order to allow you to appeal and obtain a determination on appeal before the benefit is reduced or terminated.

If you request that your course of treatment be extended beyond the period of time or number of treatments originally approved and such request is for Urgent care, the request will be decided as soon as possible, taking into account the medical exigencies. HNDV shall notify you of its benefit determination not later than 24 hours after its receipt of the claim. Your request for an extension must be made at least 24 hours prior to the expiration of the originally approved period of time or number of treatments.

Insufficient Information

If HNDV requires additional information in order to make a determination, you will be notified regarding what information is necessary and given a reasonable amount of time to provide HNDV with the requested information.

If Your Claim or Request Is Denied

If your claim or request is denied, delayed or modified due to determination that the services or treatment were not medically necessary or appropriate, either in whole or in part, you will receive a written notice explaining the reasons for the determination including:

• The specific reason or reasons why your claim or request was denied, delayed or modified.
• Reference to the specific HNDV plan provisions on which the decision is based.
• If more information is needed, a description of any material necessary to process the claim ore request properly and why the materials are needed.
• A description of HNDV's appeals process and any time limits applicable to such procedures.
• A statement explaining your right to bring a civil action under Section 502(a) of ERISA following the denial of your claim or request on appeal.
• A copy of any internal rule, guideline, protocol, or other similar criterion relied upon in denying your claim or request, or a statement that a copy will be provided to you free of charge upon request.
• If your claim or request was denied based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination applying the terms of your HNDV plan to your medical circumstances or a statement that such an explanation will be provided to you free of charge upon request.
• If your claim or request was for Urgent Care, a description of the expedited review process is available to you. This initial determination may be explained to you orally, followed by a written notice within 3 days.

Appealing A Denial of Dental/Vision Benefits

After receiving a denial, to appeal it, you or your authorized representative must submit a written request for reconsideration by HNDV. The request must be made within 180 days and should be accompanied by documents or records in support of the appeal.

As part of the review procedure, you or your authorized representative is entitled to:

• Examine and obtain copies, free of charge, of all health plan documents, records and other information that were used in making the determination.
• Submit written comments, documents, records, and other information relating to your claim or request.
• Obtain information identifying the medical or vocational experts whose advice was obtained on behalf of HNDV in connection with the denial of your claim or request. (You are entitled to this information even if HNDV did not rely on the information in making its determination).
• Have someone act as your representative in the review procedure, if you wish.

In addition, HNDV's review of your appeal must be conducted in accordance with the following rules:

• HNDV may not defer to the initial denial of your claim or request. Review of your appeal must be conducted by a HNDV's Dental or Optometric Director who is neither the individual who initially denied your claim or request, nor a subordinate of such individual.
• If denial of your initial claim or request was based in whole or in part on a medical judgment (including decisions as to whether a drug, treatment, or other item is experimental, investigational, or not medically necessary or appropriate), a HNDV Dental or Optometric Director must consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. This health care professional cannot be an individual who was consulted in connection with the initial decision on your claim or request, nor the subordinate of such an individual.
• If you are appealing the denial of a claim or request that was for Urgent Care, your request for an expedited appeal may be submitted orally or in writing, and all necessary information may be transmitted between you and HNDV by telephone, facsimile or any other available efficient method.

HNDV will notify you of the decision on your appeal:

• Urgent requests: As soon as possible, taking into account the medical emergencies, but not later than 72 hours after HNDV's receipt of your appeal.
• For Pre-service claims or requests: Within a reasonable period of time appropriate to the medical circumstances, but not later than 30 days after HNDV's receipt of your appeal.
• For Post-service claims: Within a reasonable period of time, but not later than 60 days after HNDV's receipt of your appeal.

If your appeal is denied, a written notice containing the information set forth below will be provided to you:

• The specific reason or reasons for the denial of your appeal.
• Reference to the specific HNDV plan provisions on which the denial is based.
• A statement that you are entitled to receive, upon request and free of charge, access to, and copies of, all documents, records, and other information relevant to your claim for benefits.
• A statement explaining your right to bring a civil action under Section 502(a) of ERISA following the denial of your claim on appeal, that you and HNDV may have other voluntary alternative dispute resolution options such as arbitration or mediation, and that you should contact the U.S. Department of Labor to find out what alternatives may be available.
• If an internal rule, guideline, protocol, or other similar criterion was relied upon in denying your claim or request, a copy of that rule, guideline, protocol or criterion, or a statement that a copy will be provided to you free of charge upon request.
• If your claim or request was denied based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination applying the terms of your HNDV plan to your medical circumstances or a statement that such an explanation will be provided to you free of charge upon request.

For dental and vision products licensed by the California Department of Managed Care: Under California law, you have a right to a voluntary independent medical review of denials for medical necessity or experimental/investigational services, conducted by an independent review organization contracted by the Department of Managed Health Care, "DMHC". Your HNDV Evidence of Coverage sets out the procedure for requesting IMR.