If a claim is denied, what must the plan provide?

• A. An explanation with no further steps.
• B. A payment issued automatically.
• C. An explanation and possible appeal options.
• D. A resubmission form.

Answer: (C)

When a claim is denied, the plan must send a notice that explains why the denial occurred and what the member can do next. The explanation should set out the specific reasons for the denial and the basis the plan used, so the member understands what happened and what evidence or policies were considered. Along with that, the notice must outline the options for appealing the decision, including how to initiate an internal appeal, what information or documentation may be needed, and the timeframe to submit the appeal. This combination ensures the member knows both why the claim was denied and exactly how to challenge it if they disagree. Providing only a denial explanation without any appeal steps wouldn’t give a path to review, while an automatic payment or a stand-alone resubmission form doesn’t address the requirement to communicate rights and processes for appeal.