Post-Service Claims

Post-service benefits are claims made after the treatment is received.  You or your doctor completing a claim form and submitting it for reimbursement generate these claims.

Prescription drug benefits are administered by Prescription Solutions.  Your prescription drug benefit is a so-called card-based system, and your claim is deemed made when you present the prescription and your Prescription Solutions Identification card to a participating pharmacist.

The Plan contracts with Allied Administrators, Inc. to process claims under the Self-Funded Dental Plan.  Under the Self-Funded Dental Plan and the Medicare Supplement Plan a claim form is submitted to Allied Administrators, Inc. and benefits are paid based on the benefits of each plan as described in the Summary Plan Description.  The claim is deemed made when you or your doctor file a claim with Allied Administrators, Inc.

Retired participants enrolled in the Premium Reimbursement Plan must submit a request for reimbursement as explained in the Premium Reimbursement Plan as contained in this Summary Plan Description.

Within 30 days of filing a post service claim, to the extent that any portion of your claim is denied, you will receive a notice of denial that identifies the specific Plan provision upon which the denial is based.  

The 30-day period described above may be extended as permitted by federal regulations if additional information is required to process your post-service claim.  You will be notified in writing what additional information is required in order to process your claim.

If your post-service medical claim is denied, in whole or in part, you may file an appeal with the Board of Trustees.  This appeal should be in writing and state in clear and concise terms your reason(s) for disputing the denial.  Your appeal of any post-service claim denial must be sent to the Administrative Office.

If your appeal is based upon an issue involving medical expertise, for example whether a particular service is medically necessary, the Trustees will obtain an independent expert medical opinion prior to consideration of your appeal.

If your appeal is received in the Administrative Office at least 30 days in advance of a Board of Trustees Meeting, your appeal will be considered at that meeting.  Generally, the Trustees meet no less frequently than quarterly.

To the extent permitted by federal regulations, consideration of your appeal may be put over to the next meeting of the Board if additional information is required to consider your appeal.

To assure timely consideration of appeals the Board has established an Appeals Committee of one Union and one Employer Trustee.  This committee is empowered to make final decisions if required to timely deal with appeals.  For example, when a regular Board meeting is cancelled.

When the Appeals Committee or the Board of Trustees makes a final determination on your appeal, the Administrative Office will advise you in writing within five days of the decision.