Some Questions Common to all Claims and Appeals

Question:  Who may file an appeal if my claim is denied?
Answer:  You may file the appeal yourself or you may authorize a representative (i.e., doctor, spouse, etc.) to file an appeal on your behalf.  Except in pre-service claim appeals where your doctor is acting as your representative, any representative acting on your behalf must have received written authorization from you to act on your behalf and that written authorization must be filed immediately with the Administrative Office as part of your appeal.  If you are physically or mentally incapacitated, the Trustees will waive this written authorization requirement.  It is extremely important to understand that an assignment of benefits to the provider of services does not constitute an authorization for the provider to act as your representative.

Question:  If my claim is denied, will the Plan, upon request, supply me or my representative with all documents relevant to my claim?
Answer:  Yes.  The Plan will upon request supply copies of all documents and opinions relevant to your claim in accord with federal regulations.

Question:  May I seek prior approval from the Plan for medical care that is not governed by pre-service provisions of the Plan and appeal any adverse determination under Pre-Service Rules?
Answer:  No.  Only claims for which pre-authorization is required under the Plan are subject to the expedited decision and appeal provisions pertaining Pre-Service Claims.

Question:  If my pre-service claim is denied, but I receive the medical care despite the denial and then file a claim for the medical expense incurred will this claim for medical expense be handled under the expedited provisions of Part B of these rules?
Answer:  No.  Once medical care has been provided the only issue is what, if any, portion of the bill will be paid and the provisions of post-service claims apply to the claim for medical expenses.

Question:  May the Plan and I mutually agree to extend the time frames contained in the pre-service and post-service claim rules.
Answer:  Yes.

Question:  Whom should I contact if I have questions about these new claims and appeal rules?
Answer:   You should contact the Administrative Office.

Question:  Do any provisions of these new rules change the deductibles, co-payments, exclusions or limitations contained in any of the plans?
Answer:  No.