Benefit Appeal
Procedures
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Urgent claims
are requests for eligibility status or for medical care or
treatment of an emergency nature, which could seriously
jeopardize the life or health of the claimant or would subject
the claimant to severe pain.
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A
pre-service claim is a request for eligibility status or for
benefits for which a Plan requires pre-approval, such as
predetermination of benefits for major surgery.
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A
post-service claim is a request for a benefit following the
claimant’s receipt of services.
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A decision with
respect to an urgent care claim will be made within
seventy-two (72) hours. If the claim is not complete, the Plan
will notify you of the additional information required within
twenty-four (24) hours.
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A decision on a
pre-service claim will be made within fifteen (15) days.
The Plan will advise of a defective or incomplete filing of a
pre-service claim within five (5) days of receipt. The Plan may
take an additional fifteen (15) days, if it is determined an
extension is necessary due to matters beyond the control of the
Plan and you are advised of the need for the extension.
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A decision on
a post-service claim will be made within thirty (30)
days. The Plan will advise of a defective or incomplete filing
of a post-service claim within thirty (30) days of receipt. You
will have forty-five (45) days to provide the required
information. The Plan may take an additional fifteen (15) days,
if it is necessary due to matters beyond the control of the Plan
and you are advised of the need for the extension.
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If the Plan has
approved an ongoing course of treatment to be provided over a
period of time or a number of treatments, any reduction or
termination by the Plan or such course of treatment before the
end of the period or number of treatments previously agreed will
be considered a denial. The Plan will notify you of this action
in advance of the application of the reduction or termination
and advise of the appeal rights to permit a review prior to the
date the benefit is reduced or terminated.
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A decision with
respect to extend the previously agreed to course of treatment
for an urgent care claim will be acted upon as soon as
possible. The Plan will notify you of the determination within
twenty-four (24) hours of receipt, provided the claim is made at
least twenty-four (24) hours prior to the expiration of the
prescribed period of time or number of treatments.
If your claim is denied or partially denied, you will be
notified in writing and provided an opportunity for a review.
The written notice of denial will provide:
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The specific
reason(s) for the denial;
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The specific
Plan provision on which the determination is based;
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A description
of additional information or information necessary for you to
perfect the claim and an explanation of why this additional
information is necessary;
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A statement
that the specific rule, guideline, protocol or other criterion
relied upon in making the determination, if applicable, will be
provided at no cost upon request;
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A statement
that an explanation of the scientific or clinical judgment
relied upon and the names of the individuals from whom opinion(s)
were secured, if a determination is based upon medical necessity
or experimental treatment, or similar exclusion or limit, will
be provided at no cost; and
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A description
of the Plan’s review procedures and the time limits applicable
to such procedures, including a statement regarding your right
to bring a civil action under section 502(a) of ERISA.
If your claim has either been denied or partially denied and
you are not satisfied with the decision, you may appeal the decision
and request a review of the claim. The appeal must include all of
the following:
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Be in writing
and can be made by you or your duly authorized representative;
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Should be
mailed or delivered to the Fund address shown in the Summary
Plan Description;
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Should state
the reasons you believe the initial determination was incorrect;
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Should include
any written comments, documents, records and other information
relating to the claim for benefits; and
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Be submitted
within one hundred eighty (180) days of the date you receive the
notice of denial or partial denial.
You will be
provided access to and copies of, at a reasonable charge, all
documents, records, and other information relevant to your claim.
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A decision on
review of an urgent care claim will be made within seventy-two
(72) hours after receipt of your request for review.
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A decision on
review of a pre-service claim will be made within thirty (30)
days of receipt of your request for review.
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A decision on
review of a post-service claim will be made during the course of
the regular quarterly Trustees’ meeting following receipt of the
request for review and you will be notified of the decision
within five (5) days of the date of such meeting. (If the
request for review is received within thirty (30) days of the
next regular quarterly Trustees’ meeting, the decision on review
will be made no later than the date of the second meeting
following the Plan’s receipt of the request for review.) If
special circumstances require an extension of time, a decision
will be rendered no later than the next following quarterly
Trustees’ meeting. You will be advised of the special
circumstances and the date the decision is expected to be made.
The decision of the
Trustees on review will be made in good faith and will be final and
binding on all issues. The claimant or claimant’s duly authorized
representative will be required to exhaust the entire claim review
procedure before instituting any other form of action.
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