Claims and Appeals Procedure
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CONTENTS

The Plan maintains a claims and appeals procedure which includes three major components: 

  • Filing of benefit claims;
  • Notification of benefit determinations; and 
  • Appeal of adverse benefit determinations. 

You may appoint an authorized representative to act on your behalf in pursuing a benefit claim or appeal of an adverse benefit determination. The Trustees may establish reasonable procedures for determining whether an individual has been permitted to act as an authorized representative on your behalf. In urgent care circumstances, a health care professional with knowledge of your medical condition may act as your authorized representative. 

Plan Provisions and Consistent Treatment Requirement

All administrative processes and safeguards of the Plan are administered to ensure and to verify that benefit claim determinations are made in accordance with governing Plan documents and that, where appropriate, Plan provisions treat similarly situated claimants consistently. Definitions of the terms used in this appeals procedure are set forth later in this section.

Claims for Benefits

A claim for benefits for the purpose of this Procedure is a request for a Plan benefit or benefits made by you in accordance with these procedures for filing benefit claims. This includes any pre-service and post-service claims.

Timing of Notification of Benefit Determination for Initial Claims

Urgent Care Claims 

In the case of a claim involving urgent care, the Plan will notify you of the Plan’s benefit determination (whether adverse or not) as soon as possible, taking into account the medical urgency, but not later than 72 hours after receipt of the claim by the Plan, unless you fail to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan. 

In the case of a failure by you or your authorized representative to provide enough information to determine whether, or to what extent, benefits are covered or payable under the Plan, the Plan will notify you as soon as possible, but not later than 24 hours after receipt of the claim by the Plan, of the specific information necessary to complete the claim. 

You will be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. 

The Plan will notify you of the Plan’s benefit determination as soon as possible, but in no case later than 48 hours after the earlier of:

  • The Plan’s receipt of the specified information; or
  • The end of the period afforded to you to provide the specified additional information.

Concurrent Care Decisions

If the Plan has approved an ongoing course of treatment to be provided over a period of time or number of treatments, any reduction or termination by the Plan of such course of treatment (other than by Plan amendment or termination) before the end of such period of time or number of treatments shall constitute an adverse benefit determination.

The Plan will notify you in accordance with these procedures of the adverse benefit determination at a time sufficiently in advance of the reduction or termination to allow you to appeal and obtain a determination on review of that adverse benefit determination before the benefit is reduced or terminated.

Any request by you to extend the course of treatment beyond the period of time or number of treatments that is a claim involving urgent care shall be decided as soon as possible, taking into account the medical urgency. The Plan will notify you of the benefit determination, whether adverse or not, within 24 hours after receipt of the claim, provided that any such claim is made to the Plan at least 24 hours prior to the expiration of the prescribed period of time or number of treatments. Notification of any adverse benefit determination concerning a request to extend the course of treatment, whether involving urgent care or not, shall be made in accordance with the Notification provision of these Procedures. 

Pre-Service Claims Timing Rules

If a claim is neither Urgent nor Concurrent, then it is either a pre-service claim or a post-service claim. In the case of a pre-service claim, the Plan will notify you of the Plan’s benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the claim by the Plan. 

This period may be extended one time by the Plan for up to 15 days, provided that the Plan both determines that such an extension is necessary due to matters beyond the control of the Plan and notifies you, prior to the expiration of 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 such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and you will be afforded at least 45 days from receipt of the notice within which to provide the specified information. 

Post-Service Timing Rules

In the case of a Post-service claim, the Plan will notify you of the Plan’s adverse benefit determination within a reasonable period of time, but not later than 30 days after receipt of the claim. 

This period may be extended one time by the Plan for up to 15 days, provided that the Plan: (a) determines that such an extension is necessary due to matters beyond the control of the Plan; and (b) notifies you, prior to the expiration of 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 such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension will specifically describe the required information, and you will be afforded at least 45 days from receipt of the notice within which to provide the specified information.

Calculating Time Periods 

General Rule 

The period of time within which a benefit determination is required to be made will begin at the time a claim is filed in accordance with these procedures, without regard to whether all the information necessary to make a benefit determination accompanies the filing. 

Time Periods During Extensions 

In the event that a period of time is extended as permitted due to your failure to submit information necessary to decide a claim, the period for making the benefit determination will be tolled from the date on which the notification of the extension is sent to you until the date on which you respond to the request for additional information.

Manner and Content of Notification of Benefit Determination or
Adverse Notification on Appeal

Rules for Non-Urgent Care Notification of Benefit Determination

The Plan will provide you with written notification of any adverse benefit determination of a claim or appeal.

The notification will set forth:

  • The specific reason or reasons for the adverse determination;
  • Reference to the specific Plan provisions on which the benefit determination is based;
  • A description of any additional material or information necessary for you to perfect the claim and an explanation of why such material or information is necessary;
  • A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits. Whether a document, record, or other information is relevant to a claim for benefits will be determined by reference to the definition of Relevant set forth in these Procedures;
  • A description of the Plan’s review procedures and the time limits applicable to such procedures, including a statement of your right to bring a civil action under section 502(a) of ERISA following an adverse benefit determination on review;
  • If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to you upon request; and
  • If the adverse benefit determination is based on clinical guidelines for medical appropriateness or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request.

Urgent Care Claims 

In the case of an adverse benefit determination involving urgent care, the information required by this Procedure may be provided to you orally, provided that a written or electronic notification in accordance with this section is furnished to you not later than three (3) days after the oral notification.

In the case of an adverse benefit determination concerning a claim involving urgent care, the Plan will provide, in addition to the materials described above, a description of the expedited review process applicable to such claims.

Appeal of Adverse Benefit Determinations

Following is the procedure by which you will have a reasonable opportunity to appeal an adverse benefit determination to an appropriate named fiduciary of the Plan, and under which there will be a full and fair review of the claim and the adverse benefit determination.

You have 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination.

The review on appeal will not afford deference to the initial adverse benefit determination and will be conducted by such individual, individuals or entity designated by the Trustees who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual.

In deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the Trustees, or other appropriate named fiduciary will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment.

The Plan will provide to you the identification of medical or vocational experts whose advice was obtained on behalf of the Plan in connection with your adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination.

The health care professional engaged for purposes of a consultation on appeal under these Procedures will be an individual who is neither an individual who was consulted in connection with the adverse benefit determination that is the subject of the appeal, nor the subordinate of any such individual.

Urgent Care Appeals

In the case of a claim involving urgent care, the review process shall be expedited:

  • A request for an expedited appeal of an adverse benefit determination may be submitted orally or in writing by you; and
  • All necessary information, including the Plan’s benefit determination on review, will be transmitted between the Plan and you by telephone, facsimile, or other available similarly expeditious method.

Appeals of Concurrent Care Denials 

Appeals of the denial of concurrent care claims are governed by the appeal rules of this Procedure depending on the nature of the claim as follows:

  • Urgent Care Appeal Rules;
  • Pre-service Appeal Rules; and
  • Post-service Appeal Rules.

Right to Supplement Claims 

You may submit written comments, documents, records, and other information relating to the claim for benefits.

Right to Access to Documents 

You will be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits. Whether a document, record, or other information is relevant to a claim for benefits will be determined by reference to the Definitions set forth in this Procedure. 

Right to Consideration of All Documentation 

The review will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

Urgent Care Claims

In the case of a claim involving urgent care, the Plan will notify you, in accordance with the Manner and Content of Notification on Review Provision on Appeal of this Procedure of the Plan’s benefit determination on review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of your request for review of an adverse benefit determination by the Plan.

Pre-Service Claims 

In the case of a pre-service claim, the Plan will notify you, in accordance with the Manner and Content of Notification on Review Provision on Appeal of this Procedure, of the Plan’s benefit determination on review within a reasonable period of time appropriate to the medical circumstances, but not later than: 

The Plan will provide notification not later than 30 days after receipt by the Plan of your request for review of an adverse benefit determination. 

Post-Service Appeals 

In the case of a post-service claim, the Plan will notify you, in accordance with the Manner and Content of Notification on Review Provision on Appeal of this Procedure, of the Trustees’ benefit determination on review as follows. 

The Board of Trustees will make its decision at the next regularly scheduled meeting following receipt of your appeal, unless there are special circumstances, in which case the Board of Trustees will decide the appeal at its next regularly scheduled meeting. If you submit your appeal within 30 days of the next scheduled Board of Trustees meeting, the Board of Trustees may decide the appeal at the second scheduled meeting, or, if there are special circumstances, the third meeting after it receives your appeal. If the Board of Trustees requires a postponement of its decision to the next meeting, you will receive a notice describing the reason for the delay and an expected date of the decision. 

The Board of Trustees will send you a notice of its decision within five days of the date the decision is made. The decision of the Board of Trustees is final and binding.

Informal Review by UHC

If your claim for medical or hospital benefits is denied, before appealing that denial to the Board of Trustees as described above, you may contact UHC with any questions or concerns that you have regarding the claim denial. If you choose to do so, please contact the UHC directly at 1-800-850-1418 for important information regarding the appropriate procedures, including any time limits. 

Whether or not you choose to address your concerns to UHC, you have the right to appeal a benefit denial to the Board of Trustees as described above. However, if you choose to address your concerns to UHC, you must do so before you appeal to the Board of Trustees and, if you are not satisfied with the results through UHC and wish to file an appeal to the Board of Trustees, you must do so within 180 days from the day you received the claim denial from the Fund Office or other Fund provider. If you do not choose to address your concerns to UHC and wish to appeal directly to the Board of Trustees, you must do so within 180 days from the day you received the claim denial from the Fund Office. Please remember that if you are not able to resolve your concerns by contacting UHC, you must appeal to the Board of Trustees before filing a suit against the Fund.

Furnishing Documents 

In the case of an adverse benefit determination on review, the Plan will provide such access to, and copies of, documents, records, and other information described in the Manner and Content of Notification set forth.

Definitions

“Adverse benefit determination” means any of the following:

  • A denial of a benefit;
  • Reduction of a benefit;
  • Termination of a benefit; or
  • Failure to provide or make payment (in whole or in part) for a benefit.

This includes any of the foregoing that is based on:

  • A determination of a participant’s or beneficiary’s eligibility to participate in a Plan; 
  • Application of any utilization review; or
  • A determination that a particular covered item is experimental or investigational or not medically appropriate.

“Health care professional” means a physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with State law.

“Notice” or “notification” means the delivery or furnishing of information to an individual in a manner that satisfies the standards of the Notice Section of this Procedure described below as appropriate with respect to material required to be furnished or made available to an individual.

“Post-service claim” means any claim for a benefit under a group health plan that is not a “pre-service claim.”

“Pre-service claim” means any claim for a benefit under this Plan with respect to which the terms of the Plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.

“Relevant” A document, record, or other information shall be considered “relevant” to your claim if such document, record, or other information:

  • Was relied upon in making the benefit determination;
  • Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; or
  • Demonstrates compliance with the administrative processes and safeguards required in making the benefit determination.

“Urgent Care Claim” is any claim for medical care or treatment with respect to which the applications of the time periods for making non-urgent care determinations:

  • Could seriously jeopardize your life or health or your ability to regain maximum function, or,
  • In the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Any claim that a physician with knowledge of your medical condition determines is an “urgent care claim” will be treated as an “urgent care claim.”

Documents to Be Furnished Under These Procedures 

Any material, including reports, statements and documents, required to be furnished by these procedures will be furnished using measures reasonably calculated to ensure actual receipt of the material by Plan participants and beneficiaries.