19 Notice to Claimant of Adverse Benefit Determination s Initial Claims Except with respect to Urgent Care C laims (the notification for which may be oral followed by written or electronic notification within three days of the oral notification), upon its initial determination of a C laim, the Claims Administrator shall provide written or electronic notification of any Adverse Benefit Determination . The notice will state, in a manner calculated to be understood by the c laimant: a. The specific reason or reasons for the adverse determination , including for Non - Grandfathered Plans, the denial code and its corresponding meaning, and a description of the Non - Grandfathered Plan’s standard, if any, that was used i n denying the C laim. b. Reference to the specific Welfare P rogr am provisions on which the determination was based. c. A description of any additional material or information necessary f or the claimant to perfect the C l aim and an explanation of why such material or information is necessary. d. A description of the Welfare P rogram’s appeal procedures, including any voluntary appeal pr ocedures offered by the Welfare P rogram and for Non - Grandfathered Plans, any external review procedures, and the time limits applicable to such procedures. This w ill include a statement of the c laimant's right to bring a civil action under ERISA S ection §502 . e. If the Adverse Benefit Determination was based on an internal rule, guideline, protocol, or other similar criterion, the specific rule, guideline, protocol, or criterion will be provided free of charge, or a statement will be included that such a rule, guideline, protocol, or criterion was relied upon in making the Adverse Benefit Determination and a copy will be provided free of charge to the c laimant upon request. f. If the Adverse Benefit Determination is based on a medical necessity or experimental or investigational treatment or similar exclusion or limit, an explanation of the scientific or clinical judgment for the determination, applying the terms of the Health Benefit P rogram to the c laimant's medical circumstances, will be provided, or a statement will be included that such explanation will be provided free of charge, upon request. g. For Non - Grandfathered Plans, infor mation sufficient to allo w the claimant to identify the C laim involved (including date of service , the healthcare provider, the C laim amount, if applicable, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning). h. For Non - Grandfathered Plans, information about the availability of and contact information for, any applicable office of health insurance consumer assistance or ombudsman established under applicable federal law to assist individuals with the internal clai ms and appeals procedures and external review process.