Retiree Health Summary Plan Description
En Español (PDF)

Claims & Appeal Rules

Introduction

The Claims & Appeal Rules described in this section do not apply to the following plans:

  • Kaiser HMO Medical Plan (including the Kaiser vision benefit)
  • UnitedHealthcare HMO Medical Plan
  • United Concordia PPO Plan
  • CIGNA DHMO Dental Plan
  • Delta Dental DHMO Plan
  • United Concordia DHMO Dental Plan

Benefits provided to eligible Participant and spouse by the above Health Maintenance Organizations (HMO's), Dental Health Maintenance Organizations (DHMO's) and Dental PPO Plan are subject to the claims and appeal rules established by each of the above providers. You should review the program's Evidence of Coverage document and contact the provider directly for its claims review or grievance procedure. The Administrative Office can provide you with information on where to write.

On or after July 1, 2002 the following rules have been adopted by the Trustees regarding all eligibility appeals and claims appeals for those enrolled in the Mandatory Generic Prescription Drug Plan, the Medicare Supplement Plan and the Premium Reimbursement Plan.:

This section added by: Amendment 10.
Please note that effective January 1, 2016, the Medicare Supplement Plan is not an option for retirees and their eligible spouses who are enrolled in one of the Retiree Health Plan options other than the Medicare Supplement Plan or who first become covered under the Retiree Health Plan on or after that date.

 
It is the intent and desire of the Trustees that these rules be consistent and comply with applicable regulations, including but not limited to 29 CFR 2560. et. seq. These rules shall be construed in accord with that intent. Those regulations are incorporated here as though set forth in full. The regulations shall be construed in accord with Department of Labor guidance issued subsequent to issuance of the regulations.