Types of Claims
How a claim is handled will depend upon the type of claim presented. The types of claims are:
The time within which the Fund must respond to a claim from a participant or a beneficiary depends upon which type of claim is presented.
Urgent Care Claim - A claim involving urgent care is a claim for medical care or treatment with respect to which the time period for making determinations must be substantially reduced because the normal time periods could seriously jeopardize the life or health of the participant or beneficiary, or the ability of the participant or beneficiary to regain maximum function, or which could subject the participant or beneficiary to severe pain that cannot be adequately managed without the urgent care being delivered.
| Benefit Determination Time Frame | 72 hours |
| Who can Present the Claim? | Participant, Beneficiary, Representative or the Doctor |
| How can the Claim be Presented? | Orally unless the participant or beneficiary or representative requests that it can be made in writing. |
| What if the Claim Presented is Incomplete or Insufficient? | The Fund must advise you within 24 hours if the claim fails to provide sufficient information to make a decision. |
| How Long After I Receive Notification of a Claim Denial do I have to Submit an Appeal? |
If your claim has been denied in whole or in part, you are permitted to present your appeal within 180 days of the claim denial. You should bear in mind that if you are appealing an urgent care claim, you must do so promptly in order to maintain the early responses for appeals of such claims. |
| How Long will the Fund Take to Decide my Appeal? | The Fund will notify you of the results not later than 72 hours after the Fund receives your request for review of the full or partial denial of your claim. |
Pre-Service Claims - These claims are submitted before services are rendered and do not meet the definition of "urgent care claims."
| Benefit Determination Time Frame | 15 Days |
| Who can Present the Claim? | Participant, Beneficiary, Representative or the Doctor |
| How can the Claim be Presented? | Orally or in writing by a participant or authorized representative, including a participant or beneficiary's doctor. |
| What if the Claim Presented is Incomplete or Insufficient? | Under certain circumstances, the time the Fund may take to respond to your claim may be extended an additional 15 days. |
| How Long After I Receive Notification of a Claim Denial do I have to Submit an Appeal? |
If your claim has been denied in whole or in part, you are permitted to present your appeal within 180 days of the claim denial. |
| How Long will the Fund Take to Decide my Appeal? | The Fund will provide you with notice of the determination of your appeal not later than 30 days after it receives your request for review of a full or partial denial of your pre-service claim. |
Post Service Claims - Most claims are post-service claims where you are requesting payment to your doctor or other medical provider, or reimbursement to yourself of some or all of the charges previously incurred for medical services that have already been rendered.
| Benefit Determination Time Frame | One year from the date of service in accordance with Plan rules. |
| Who can Present the Claim? | Participant, Beneficiary, Representative or the Doctor |
| How can the Claim be Presented? | The claim can be submitted in writing by you, in writing by your doctor or other health care provider or electronically by your doctor or other health care provider in accordance with nationally recognized "electronic data transmission" standards. |
| What if the Claim Presented is Incomplete or Insufficient? | The Fund will normally make a decision within 30 days of the date in which the claim is received. If the issues involved are complicated, the Fund may extend that time by an additional15 days, but will advise you if it has made a determination to do so. Sometimes the Fund will request additional information from you, and will tell you that you may submit that information within a period of up to 45 days. Under these circumstances the time to decide the claim can be extended up to an additional 45 days. |
| How Long After I Receive Notification of a Claim Denial do I have to Submit an Appeal? |
If your claim has been denied in whole or in part, you are permitted to present your appeal within 180 days of the claim denial. |
| How Long will the Fund Take to Decide my Appeal? | The Fund will provide to you a response within a reasonable period of time and as quickly as appropriate under the circumstances.* |
*If the appeal is handled through internal procedures, including use of outside medical personnel, the decision on appeal will be provided to you not later than 60 days after receipt of your request for review, unless the Fund determines that special circumstances require an extension of time. If this is the case, that extension will not exceed 60 additional days.
If the appeal requires consideration by the EWTF Board of Trustees, then the Trustees will consider the appeal at the next regular meeting of the Board of Trustees, unless the request for review was filed within 30 days of the next scheduled meeting. If that is true, the appeal will be heard on the next scheduled meeting. In extremely special occasions requiring additional time, the benefit determination may not be made until the third meeting of the Board of Trustees. If that happens, you will be notified within 5 days after the meeting of the Board of Trustees.