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.
Notwithstanding the above, providers of No Surprises Services will receive payment, or a denial, of a post-service claim within 30 days of the Plan’s receipt of all information necessary to adjudicate the claim.>
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.
External Review of Denied Claims
If you receive a Final Internal Adverse Benefit Determination regarding a No Surprises Service, you may appeal that Determination to an external independent review organization (IRO). Claim denials for any service other than a No Surprises Service are not subject to external review.
A request for external review must be filed with the Plan within four months after you receive notice of the Final Internal Adverse Benefit Determination, or by the first day of the fifth month after you received the Final Internal Adverse Benefit Determination, if earlier.
Preliminary Review. Within five business days of receiving your external review request, the Fund and, if applicable, the IRO, will complete a preliminary review of your request to determine whether it is eligible for external review.
Within one business day after the preliminary review is complete, you will be advised of the decision. If your claim is not eligible for external review, the notice will state the reason(s) it is not eligible and will provide you with contact information for the Employee Benefits Security Administration. If your external review request is not complete, the notice will describe the information or materials needed to complete your request. You may submit the additional required information within the original four-month filing period or within the 48-hour period following your receipt of the preliminary review decision, whichever is later.
Referral to Independent Review Organization. If your external review request is complete and your claim is eligible for external review, your claim will be forwarded to an IRO for review. The IRO will notify you in writing that your claim has been accepted for external review and that you may submit to the IRO in writing, within ten business days, additional information for the IRO to consider when conducting its external review. The IRO may, but is not required to, accept and consider additional information submitted after ten business days.
If you choose to submit additional information, the IRO will forward the information to the Fund within one business day. The Fund then may reconsider its adverse benefit determination. However, reconsideration by the Fund will not delay the IRO’s review. If the Fund decides to reverse its adverse benefit determination based on the additional information, the Fund will provide written notice of its decision to you and the assigned IRO within one business day after making such a decision. Upon receipt of such notice from the Fund, the assigned IRO will terminate the external review.
In making its decision, the IRO will review all of the information and documents it timely receives and will not be bound by any decisions or conclusions reached during the Fund’s internal claims and appeals process. In addition, the IRO may consider additional information relating to your claim to the extent the information is available and the IRO considers it to be relevant.
The IRO will provide you with written notice of its external review decision within 45 days after receiving the request for the external review. The IRO’s decision notice will contain:>
- A general description of the claim and the reason for the external review request, including the date(s) of service, the health care provider, the claim amount (if applicable), the diagnosis code, the treatment code and the reason for the previous denial);
- The date the IRO received the external review assignment and the date of its decision;
- Reference to the evidence considered in reaching its decision;
- A discussion of the principal reason(s) for its decision, including any evidence-based standards that it relied on in making its decision;
- A statement that the determination is binding except to the extent that other remedies may be available under state or federal law;
- A statement that judicial review may be available to you; and
- Contact information for any applicable consumer assistance office.
Upon request, the IRO will make available to you its records relating to your request for external review, unless such disclosure would violate state or federal privacy laws.
Reversal of the Fund’s decision. If the Fund receives a final external review decision that reverses its adverse benefit decision, the Fund immediately will provide coverage or payment of the claim in accordance with the terms of the Plan.
Review by UHC
Pre-Service Claims
If your pre-service claim for medical or hospital benefits is denied, before appealing that denial to the Board of Trustees as described above, you may submit a first level appeal to UHC.
You, your physician or your health care professional have the right to request the information reviewed to make this coverage decision free-of-charge. This includes reasonable access to and copies of all documents, records, health benefit plan provisions, internal rules, guidelines and protocols and any other relevant information. Please mail your request for this information to:
UMR Inc.
Attn: UMR Care Management
P.O. Box 8042
Wausau, WI 54402-8042
You have the right to be represented by someone else regarding this decision. To have someone else represent you, call us at the toll-free number on your member ID card and UHC will send you the form needed to designate another representative.
The following information is helpful to submit to UHC when appealing a pre-service claim denial:
A written appeal request asking for reconsideration of the decision
The specific coverage decision you would like to have reviewed
An explanation of why the requested service should be considered for coverage
Any additional information that supports your position
A copy of the denial letter
Mail or fax this information to:
UHC Appeals – UMR, Inc.
P.O. Box 400046
San Antonio, TX 78229
FAX: 1-888-615-6584
The person who reviews your appeal will not be the person, or subordinate of that person, who made the original decision.
Typically, you have 180 days from your receipt of the claim denial letter to submit an appeal request. If you don’t comply with these requirements, you may forfeit your right to appeal. When UHC receives an appeal request, it review the appeal within 15 calendar days and will notify you of its decision in writing.
If you submit a first level appeal of your pre-service claim to UHC and receive an adverse determination on appeal, you have the right to appeal the benefit denial to the Board of Trustees as described above. If you wish to file an appeal to the Board of Trustees, you must do so within 60 days from the day you received UHC’s appeal denial. Please remember that if you are not able to resolve your concerns through your appeal to UHC, you must appeal to the Board of Trustees before filing a suit against the Fund.
Post-Service Claims
If your post-service 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 original claim denial. 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.