Claims
and Appeals Rules
I. Claim Denial
- Processing
of Claims. Claims that are properly filed
will be processed in accordance with the following
guidelines:
- Post-Service
Health Claims. A
post-service claim is any properly filed claim for medical, dental, vision, or
prescription drug benefits that is not a pre-service claim. A post-service claim
will generally be processed within 30 days of receipt. This period may be
extended for up to 15 days if the plan determines an extension of time for
making the determination is necessary due to matters beyond the control of the
plan, and notifies the employee or beneficiary (hereafter
“claimant”) within the initial 30-day period of the circumstances
requiring the extension of time and the date by which the plan expects to render
a
decision.
If
an extension is necessary due to the claimant’s failure to submit the
information necessary to process the claim, the notification of the extension
will describe the necessary information, and the claimant will be provided at
least 45 days from receipt of the notification to submit the additional
information. The period for making a determination will be tolled from the date
on which the notification of the extension is sent to the claimant until the
date on which the claimant responds to the request for additional
information.
- Pre-Service
Claims. A pre-service claim is a properly
filed claim which must be preauthorized to receive full benefits from the plan.
Pre-service claims include, but are not limited to: hospital admissions,
surgeries requiring a second opinion, certain prescription drugs, durable
medical equipment, and home health care. A pre-service claim will generally be
processed within 15 days of receipt. This period may be extended for up to 15
days if the plan determines an extension of time for making the determination is
necessary due to matters beyond the control of the plan, and notifies the
claimant within the initial 15-day period of the circumstances requiring the
extension of time and the date by which the plan expects to render a
decision.
If
an extension is necessary due to the claimant’s failure to submit the
information necessary to process the claim, the notification of the extension
will describe the necessary information, and the claimant will be provided at
least 45 days from receipt of the notification to submit the additional
information. The period for making a determination will be tolled from the date
on which the notification of the extension is sent to the claimant until the
date on which the claimant responds to the request for additional
information.
If
services that require preauthorization have been provided and the only issue is
what payment, if any, will be made, the claim will be processed as a
post-service claim.
- Pre-Service
Urgent Care Claims. Pre-service urgent
care claims are claims with respect to which the normal time frames for review
of a claim could seriously jeopardize the life or health of the claimant, or
expose the claimant to severe pain that could not adequately be managed without
the care or treatment that is the subject of the
claim.
This
plan does not require precertification of urgent care
claims.
If
an insured needs medical care for a condition which could seriously jeopardize
his or her life or health, there is no need to contact the plan administrator
for prior approval. The insured should obtain such care without
delay.
Further,
if the plan does not require the insured to obtain approval of a medical service
prior to getting treatment, then there is no pre-service claim. The insured
simply follows the plan’s procedures with respect to any notice which may
be required after receipt of treatment, and files the claim as a post-service
claim.
- Concurrent
Care Claims. Concurrent care claims are
pre-service claims involving an ongoing course of treatment to be provided over
a period of time or number of treatments, and either (a) the plan determines
that the course of treatment should be reduced or terminated, or (b) the insured
requests extension of the course of treatment beyond that which the plan has
approved.
A
claim to extend the course of treatment beyond the period of time or number of
treatments previously approved will be treated as a new claim and processed
within the timeframes appropriate to the type of claim. If the plan reduces or
terminates a course of treatment before the end of the previously approved
period or number of treatments, the plan will notify the claimant in advance of
the reduction or termination to allow the claimant to appeal and obtain a
determination on review before the benefit is reduced or terminated.
- Time
Loss Claims. Claimants will be notified of
a determination on a claim for time loss benefits within 45 days after receipt
of the claim by the plan. This period may be extended for up to 30 days (to a
total of 75 days) if the plan determines that an extension of time for making
the determination is necessary due to matters beyond the control of the plan,
and notifies the claimant prior to the expiration of the initial 45-day period
of the circumstances requiring the extension of time and the date by which the
plan expects to render a decision. If the plan determines that an additional
extension of time for making the benefit determination is necessary due to
matters beyond the control of the plan, and notifies the claimant prior to the
expiration of the first 30-day extension period of the circumstances requiring
the extension of time and the date by which the plan expects to render a
decision, then the period for making a benefit determination may be extended by
the plan for an additional 30 days (to a total of 105
days).
If
an extension is necessary due to the claimant’s failure to submit
information necessary to process the claim, the notification of the extension
will describe the necessary information, and the claimant will be provided at
least 45 days from receipt of the notification to submit the additional
information. The period for making a determination will be tolled from the date
on which the notification of the extension is sent to the claimant until the
date on which the claimant responds to the request for additional
information.
- Notification
of Claim Denial. If a claim is denied or
partly denied, the claimant will be notified in writing and given an opportunity
for review. The written denial will
give:
- The
specific reasons for the denial.
- Specific
reference to pertinent plan provisions on which the denial is based.
- A
description of any additional material or information necessary for the claimant
to perfect the claim and an explanation of why such material or information is
necessary.
- If
an internal rule, guideline, protocol, or other similar criterion was relied
upon in making the adverse determination, either the specific rule, guideline,
protocol, or other similar criterion, or a statement that such a rule,
guideline, protocol, or other similar criterion was relied upon in making the
determination and that a copy of the same will be provided free of charge to the
claimant upon request.
- If
the denial is based on medical necessity or experimental treatment or a similar
exclusion or limit, either an explanation of the scientific or clinical judgment
for the determination, applying the terms of the plan to the claimant’s
medical circumstances, or a statement that such an explanation will be provided
free of charge upon request.
- An
explanation of the plan’s claim review procedure, including a statement of
the claimant’s right to bring a civil action under ERISA §
502(a)
II. Appeal
To Board of
Trustees
- Notification
of Appeal. Any employee or beneficiary
(hereafter “claimant”) who applies for benefits and is ruled
ineligible by the Trustees (or by the administrator acting for the Trustees), or
who believes he or she did not receive the full amount of benefits to which he
or she is entitled, or who is otherwise adversely affected by any action of the
Trustees, will have the right to appeal to and request review of the matter by
the Board of Trustees, provided that he or she makes such a request, in writing,
within 180 days after the Trustee’s action or within 180 days after
receipt of the notification or
decision.
The
appeal will be conducted by the Board of Trustees, or by the Appeals Committee
of the Board of Trustees, which has been allocated the authority for making a
final decision in connection with the appeal.
- Scheduling
of Appeal. Except for claims involving
pre-service, the Trustees will review a properly filed appeal at the next
regularly scheduled quarterly meeting of the Appeals Committee, unless the
request for review is received by the Trustees within 30 days preceding the date
of such meeting. In such case, the appeal will be reviewed no later than the
date of the second quarterly meeting following the Trustee’s receipt of
the notice of appeal, unless there are special circumstances requiring a further
extension of time, in which case a benefit determination will be rendered not
later than the third quarterly meeting of the Appeals Committee following the
Trustee’s receipt of the notice of appeal. If such an extension of time
for review is required because of special circumstances, such as a request for a
hearing on the appeal, then prior to the commencement of the extension, the plan
will notify the claimant in writing of the extension, describe the special
circumstances and the date as of which the benefit determination will be
made.
The
Trustees will review a properly filed appeal of a pre-service claim within 30
days after receipt of the appeal.
- Appeal
Procedures. A claimant is generally
entitled to present the claimant’s position and any evidence in support
thereof, at an appeal hearing. Notwithstanding the foregoing, in order to
expedite review, the appeal of a pre-service or post-service claim may be held
telephonically by the Trustees, and unless the participation of the claimant or
his or her representative is necessary to develop an adequate record, may
be based upon the written record. The claimant may request postponement of the
Trustees’ review if the claimant wishes to appear in person at a
hearing.
A
claimant may be represented by an attorney or by any other representative of his
choosing at his or her own
expense.
The
claimant will be provided upon request and free of charge, reasonable access to,
and copies of, all documents, records and other information relevant to his or
her claim for
benefits.
The
claimant must introduce sufficient credible evidence on appeal to establish,
prima facie, entitlement to the relief from the decision or other action from
which the appeal is taken. The claimant will have the burden of proving his or
her right to relief from the decision or action appealed, by a preponderance of
evidence. The Trustees will review all comments, documents, records and other
information submitted by the claimant related to the claim, regardless of
whether such information was submitted or considered in the initial benefit
determination. The Trustees will not afford deference to the initial adverse
benefit
determination.
When
deciding an appeal of a claim that is based in whole or in part on a medical
judgment, the Trustees will consult with a health care professional who has
appropriate training and experience in the field of medicine involved in the
medical judgment. Any medical or vocational expert whose advice was obtained on
behalf of the plan in connection with the adverse benefit determination will be
identified to the claimant upon request. Any health care professional engaged
for the purpose of a consultation on a claim will not be an individual who was
consulted in connection with the initial adverse benefit determination that is
the subject of the appeal, nor the subordinate of any such
individual.
- Decision
After Appeal Hearing. The Trustees will
issue a written decision on review of a claim (other than a pre-service claim)
as soon as possible, but not later than 5 days following the conclusion of the
Appeals Committee meeting. Where necessary, the Trustees may issue a more
detailed explanation of the reasons for an adverse decision within 30 days of
the conclusion of the Appeals Committee meeting. Notwithstanding the foregoing,
a decision on review of a pre-service claim will be made within 30 days after
receipt of the appeal. In the case of an adverse benefit determination, the
written denial will
indicate:
- The
specific reasons for the adverse benefit determination and a specific reference
to pertinent plan provisions on which the denial is based.
- A
statement that the claimant is entitled to receive, upon request and free of
charge, reasonable access to, and copies of all documents, records, and other
information relevant to the claimant’s claim for benefits.
- If
an internal rule, guideline, protocol, or other similar criterion was relied
upon in making the adverse determination, either the specific rule, guideline,
protocol, or other similar criterion, or a statement that such a rule,
guideline, protocol, or other similar criterion was relied upon in making the
determination and that a copy of the same will be provided free of charge to the
claimant upon request.
- A
statement of the claimant’s right to bring a civil action under ERISA
§ 502(a).
III. Review
of Trustees’ Decision
The
plan does not provide for any voluntary alternative dispute resolution
procedures. If a claimant remains dissatisfied with the plan’s
determination after exhausting the claim appeal procedures, the claimant may
bring a civil action under ERISA § 502(a). The question on review of the
Trustees’ determination will be whether, in the particular instance, the
Trustees: (1) were in error upon an issue of law; (2) acted arbitrarily or
capriciously in the exercise of their discretion; or (3) whether their findings
of fact were supported by substantial evidence.
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