Batch # 34292073

12/6/2023

REQUEST FOR ADDITIONAL INFORMATION OR NOTICE OF ADVERSE DETERMINATION

This document serves as a request for additional information and/or a denial, in whole or in part, for the requested
reimbursement as indicated below. Any requested information must be submitted within 45 days of your receipt
of this notice. We presume you will receive this notice within five days of the date above. If we do not receive the
requested information within the timeframe indicated that portion of your claim shall be considered denied.

To: Knoll, Colleen

7720 Madeline Drive
Yorkville, IL 60560

Employer: Oswego CUSD 308

Claimed amount $351.80

We have approved $0.00

We are denying $351.80

Denied item(s):

Service date(s): 9/18/2023 Amount: $351.80

This expense requires a Letter of Medical Necessity (LMN). The treatment start date on the LMN must
be on or before the service or purchase date. A template for the LMN can be downloaded from
http://portal.naviabenefits.com/pdf/mednecessity.pdf for your healthcare provider to complete to
confirm that this item is medically necessary. Your claim may be resubmitted with a completed LMN.

Christian Hufancia
(425) 452-3500
csclaims@naviabenefits.com

Navia Benefit Solutions

PO Box 53250, Bellevue, WA 98015-3250
Website www.naviabenefits.com
(425) 452-3500
 Batch # 34292073
12/6/2023
You have a right to appeal a denial by following the appeal procedures described below. This procedure is intended to provide a full and fair
review of your claim.

LEVEL ONE BENEFIT DENIAL REVIEW TO NAVIA BENEFIT SOLUTIONS

You must request an appeal in writing within 180 days of the date you received a claim denial notice. You must include an explanation as to
why you are appealing the denial. You may also submit written comments, documents, records, and any other information relating to the claim.
Upon written request and free of charge, you will be provided reasonable access to, and copies of, all documents, records, and other
information relevant to the claim. This would include comments, documents, records, and other information that either was not submitted
previously or was not considered in the initial benefit decision. The review of your appeal will give no deference to the initial decision. It will be
conducted by the Navia Review Committee and not anyone involved in the initial denial decision. You must file your appeal by submitting a
written request by email, fax, or mail.

 Email all materials to claims@naviabenefits.com with “LEVEL ONE REQUEST FOR REVIEW OF BENEFIT DENIAL” in the subject line.
 Mail all materials to Navia Benefit Solutions Level One Review, PO Box 53250, Bellevue, WA 98015

TIME PERIODS FOR APPEAL

You will be notified of the decision no later than 30 days after Navia receives your appeal. The Plan may extend this period by a reasonable time
if necessary.

Please carefully review the above information. If you decide to appeal this denial by requesting a review as described above, your appeal should
be sent within the prescribed time period to the person named above.

Failure to file a timely appeal will bar you from any further review of this benefit denial under these procedures or in a court of law.

LEVEL TWO BENEFIT DENIAL REVIEW TO THE EMPLOYER (FINAL APPEAL)

You must request an appeal in writing within 60 days of the date you received notice of the Level One Denial of Benefits. You may submit
written comments, documents, records, and any other information relating to the claim. Upon written request and free of charge, you will be
provided reasonable access to, and copies of, all documents, records, and other information relevant to the claim. The review of your level two
appeal will take into account all comments, documents, records, and other information submitted that relates to the claim. This would include
comments, documents, records, and other information that either was not submitted previously or was not considered in the initial benefit
decision. The review of your appeal will give no deference to the initial decision. It will be conducted by the Employer’s Review Committee and
not anyone involved in the initial denial decision.

You must file your appeal by submitting a written request by email, fax, or mail.

 Email all materials to claims@naviabenefits.com with “LEVEL TWO REQUEST FOR REVIEW OF BENEFIT DENIAL” in the subject line.
 Mail all materials to Navia Benefit Solutions Level Two Review, PO Box 53250, Bellevue, WA 98015

TIME PERIODS FOR APPEAL

You will be notified of the decision no later than 30 days after Navia receives your appeal and forwards the appeal to your employer. The Plan
may extend this period by a reasonable time if necessary.

You have a right to bring a civil action under ERISA § 502(a) if applicable if you file a final appeal and your request for benefits is denied
following review of the appeal.

Please carefully review the above information. If you decide to appeal this denial by requesting a review as described above, your appeal should
be sent within the prescribed time period to the person named above.

Failure to file a timely appeal will bar you from any further review of this benefit denial under these procedures or in a court of law.

The above appeals process does not apply to Wellness Plan denials.

Navia Benefit Solutions

PO Box 53250, Bellevue, WA 98015-3250
Website www.naviabenefits.com
(425) 452-3500