Claims Procedures

Definition of a Claim

A claim is a request for Plan benefits made in accordance with the Plan’s claims procedures.  Should you be required to file the claim yourself, you will need to complete a Claim Form and attach an itemized statement from your provider which includes your name, identification number, the date of service, procedure code or description and diagnosis code.

When you go to a physician’s office, hospital or any provider of medical services, you should present your medical identification card.  The provider of services can use this ID card to contact the Fund Office and inquire as to your eligibility for coverage and the Plan’s benefits.

In verifying eligibility and Plan benefits, the Fund Office staff will use the information which is currently available; however, this verification is not a guarantee of eligibility or benefits.  When the Fund Office receives claims for benefits, the claims are processed in accordance with the Plan’s provisions and the Fund’s records regarding eligibility.

Assignment

In most cases, your physician’s office, the hospital or provider of services will allow you to assign benefits so any payments made for expenses due to medical care and treatment by the Plan can be issued directly to the provider of services.

Submitting Claims 

Your claim will be considered to have been filed as soon as it is received by the Fund Office.  The Plan will accept a paper claim (mailed or delivered to the Fund Office) or an electronic claim.

The submission of a provider’s claim to the provider’s billing agent or clearinghouse does not constitute receipt of a claim by the Plan.

Timely Filing Limit

Your claim must be submitted within twelve (12) months of the date of service to be eligible for reimbursement under the Plan.  Failure to submit a claim within the one year timely filing limit will result in the claim being denied with no benefits payable.

As a participant in the Plan, you are responsible for verifying the provider has submitted your claim.  When the claim is processed by the Plan, both you and the provider will receive an Explanation of Benefits (also known as an EOB) explaining how the claim was processed. 

Should a claim be submitted and not have the required information or documentation, both you and the provider will be notified that your claim has been received and is pending additional information or clarification before the benefit processing can be completed.

Payment of Claim

Payment of benefits will be made at regular intervals occurring at least once every thirty (30) days.  When payment is made, you will receive an Explanation of Benefits (EOB) which will explain how the claim was processed.  Included on this EOB is the provider’s original charge, the allowable amount, any deductible amount and Plan payment.  This EOB will also show your member liability.  You may receive a bill from the provider for any remaining expense, which will be your responsibility to pay.  Should there be no member liability, you will also receive an EOB showing the allowable amount was paid in full.  You should always retain all EOBs and notices from the Plan for your records.

If you pay an In-Network provider at the time of service, you may need to contact the provider about any refund should your member liability be less than your payment after the Plan processes your claim.

If your claim for benefits is denied, you have the right to file an appeal.

Not in Lieu of Workers’ Compensation

The provisions of the Plan are not in lieu of, and shall not affect any requirements for coverage by Workers’ Compensation insurance.

Plan Change or Termination

The Trustees reserve the right to change or discontinue the type and amounts of benefits under the Plan and the eligibility rules for extended or accumulated eligibility, even if extended eligibility has already been accumulated.

Plan Benefits and eligibility rules for active, retired or disabled participants:

• Are not guaranteed;
• May be changed or discontinued by the Board of Trustees;
• Are subject to the rules and regulations adopted by the Board of Trustees;
• Are subject to the Trust Agreement which establishes and governs the Fund’s operations; and
• Are subject to the provisions of any group insurance policy purchased by the Board of Trustees.

The nature and amount of Plan benefits are always subject to the actual terms of the Plan as it exists at the time the claim occurs.

If the Plan is changed or discontinued, it will not affect your or your beneficiary’s right to any insured benefit to which you have already become entitled.