Claims & Appeal Rules

Introduction

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

1. Kaiser HMO Medical Plan (includes the Kaiser vision benefit)
2. PacifiCare HMO Medical Plan
3. CIGNA Dental Plan
4. PMI Dental Plan
5. United Concordia Dental Plan
6. Safeguard Dental Plan
7. Metropolitan Life Insurance Plan

Benefits provided by the above Health Maintenance Organizations (HMO’s), Dental Maintenance Organizations (DMO’s) or Metropolitan Life Insurance Company are subject to the claims and appeal rules established by each of the above providers.  You should contact the provider directly for its claims review or grievance procedure.  The Administrative Office can provide you with information on where to write.

Effective July 1, 2002 new federal regulations apply to the processing of claims and appeals.  The following rules have been adopted by the Trustees to cover claims and appeals for participants enrolled in any of the following plans:

1. Self-Funded Indemnity Plan
2. Mandatory Generic Prescription Drug Plan
3. Self-Funded Dental Plan
4. Self-Funded Vision Service Plan (except Kaiser participants-Kaiser maintains its own plan)
5. Integrated Member Assistance Program & Managed Mental Health & Chemical Dependency Benefits Program (except Kaiser participants- Kaiser maintains its own plan)

It is the intent and desire of the Trustees that these rules be consistent and complies 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.

Pre-Service Claims

Pre-service claims are claims for benefits that the Plan requires pre-authorization before you receive medical care.

For all of the plans listed above, there are no pre-authorization (prior approval) requirements for urgent medical care or medical emergencies.  If you require urgent medical care, you should seek immediate medical attention or dial 911 as may be required.

Self-Funded Indemnity Plan

The Plan contracts with Anthem Blue Cross of Southern California to process all claims under the Self-Funded Indemnity Plan.  Participants enrolled in the Self-Funded Indemnity Plan will continue to have access to the Anthem Blue Cross PPO, called the Prudent Buyer Plan.
 
For example, if you experience chest pains and believe you are having a heart attack, you do not need to get approval from the plan to seek medical care.  The plan would consider this urgent care/medical emergency.  Provided you are eligible for benefits under the Self-Funded Indemnity Plan, you will be covered for plan benefits.

In the event of a medical emergency or urgent care (such as surgery or hospitalization), you should notify Anthem Blue Cross within 24 hours of being admitted as an inpatient or as soon thereafter as possible.  This is so that Anthem Blue Cross can manage your claim to ensure that you are receiving treatment only for medically necessary care and that your hospital stay is not excessive.  If you do not notify Anthem Blue Cross, you will still be eligible for plan benefits for medically necessary services.

In order to receive full benefits, the Self-Funded Indemnity Plan requires that all non-emergency hospitalizations be approved (pre-authorization) before you are admitted to the hospital.  This is explained within the Summary Plan Description under the heading entitled "Required Hospital Pre-Certification Program – Penalty for Non-Compliance".  If you do not notify Anthem Blue Cross, you will still be eligible for plan benefits for medically necessary services, but you may be subject to a $500 reduction in benefits as explained in the Summary Plan Description.  

If you are planning to have non-emergency hospitalization, you or your doctor should call Anthem Blue Cross at 1-800-543-3037 to receive prior authorization.  Again, this requirement is not applicable to any medical care that is considered "urgent care" by you or your doctor.

For medical claims involving routine pre-certification for non-emergency hospitalizations and elective surgery, the claim regulations require that you be advised of a decision within a 15-day turn around.  Generally, Anthem Blue Cross will advise you of their decision within three business days.

Integrated Member Assistance Program and Managed Mental Health & Chemical Dependency Benefits Program

The Plan contracts with PacifiCare Behavioral Health (PBH) to process all mental health and chemical dependency claims.  This program is described in the section of the "Summary Plan Description" subtitled "Submission of Claims".  

As described in the "Summary Plan Description" under the heading "Important:" you will only be eligible for inpatient benefits provided by a PBH-contracted Network Facility. This applies to both Mental Health and Chemical Dependency Treatment.

In cases of emergency admissions to a contracted PBH Network Facility, you should contact PBH within 48 hours or as soon thereafter as possible.  This is for the purpose of having PBH manage your stay.  In the event you do not notify PBH, you will still be eligible for plan benefits for medically necessary services.  

PacifiCare Behavioral Health maintains a 24-hour toll free hotline at 1-877-225-2267.  You can access this hotline at any time to find out how to receive treatment for mental health and/or chemical dependency needs.

Other Plans

There are no pre-certification requirements for urgent care under the Prescription Drug Program, Self-Funded Dental Plan or the Vision Plan.

Independent Medical Opinions

These pre-service claims and appeals involve issues predicated upon medical necessity and the appropriateness of requested medical care.  While the Board of Trustees are the named fiduciaries responsible for the final determination of your pre-service appeal, the Board of Trustees does not possess medical expertise.  Therefore, the Board has established a policy of adopting as its own opinion the opinion(s) received from outside independent medical doctors and review organizations, which is most favorable to you.

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.

For example, under the Self-Funded Indemnity Plan, you may have routine doctor office visits.  If you use a Anthem Blue Cross Prudent Buyer provider, there may be no claim forms for you to complete. However, your claim will be deemed made when the PPO provider transmits the claim to Anthem Blue Cross. If you use a medical provider who is not on the Anthem Blue Cross PPO, then a claim form will need to be completed and mailed to Anthem Blue Cross.  Claim forms are available from Anthem Blue Cross of Southern California.  The claim is deemed made when you or your doctor file a claim with Anthem Blue Cross of Southern California.

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 this plan a claim form is submitted to Allied Administrators, Inc. and benefits are paid based on a schedule of dental allowances.  The claim is deemed made when you or your doctor file a claim with Allied Administrators, Inc..

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.  For example, a claim or a portion thereof may not be payable under the Self-Funded Indemnity Plan because the annual deductible has not been met.

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.

Eligibility Issues

Eligibility for plan coverage is explained in the "Summary Plan Description" under the section entitled "Eligibility & General Plan Provisions" of the Summary Plan Description.

The Administrative Office is responsible for maintaining eligibility.  Each month the Administrative Office provides all benefit providers to the Trust, such as Anthem Blue Cross, Kaiser, PacifiCare, with a listing of eligible participants.

There may be instances where a plan participant has a claim denied because he or she has not met the plan rules to be eligible for benefits under the plan.  There are many reasons why this can happen.

For illustrative purposes several examples are cited below.

Example 1:  A participant may not work the required hours to be eligible for benefits as explained in the "Eligibility & General Plan Provisions" of the Summary Plan Description.  

Example 2:  A participant has worked the required hours in covered employment but his or her employer has not remitted the required health and welfare contributions to the plan.

Example 3:  A participant does not work the required 100 hours per month to maintain eligibility and his or her bank hours have been depleted to zero, or there are not enough hours left in the hours bank to establish eligibility.

Example 4:  A participant is no longer working and the participant has elected COBRA continuation coverage, but he or she has failed to make the required self-payment to be eligible for continuation coverage.

Most eligibility issues are resolved quickly with a call or a letter to the Administrative Office. The Administrative Office is there to assist you and provide you with exact information on the status of your eligibility and entitlement to benefits under the various plans.

If you have a claim denied because you do not meet the eligibility requirements of the plan you have the right to appeal this denial.  Your appeal should be in writing, and be sent to the Administrative Office.  You should state in your appeal why you believe you meet the eligibility requirements (refer to "Eligibility & General Plan Provisions" of the Summary Plan Description), and provide any factual information you believe is important in having your appeal reviewed.

Your appeal will be considered within the appropriate time parameters described in the sections above entitled "Pre-Service Claims" and "Post Service Claims".  Some examples are provided below.

For example, assume you want pre-certification for non-emergency elective surgery under the Indemnity Plan (Pre-Service Claim), and your claim is denied because you are not eligible for benefits, you then have the right to appeal this decision.  If you appeal the claim denial, the Administrative Office will respond to your appeal within 15 days from the date your appeal is received in writing in the Administrative Office.

For example, assume you submit a dental claim (Post-Service Claim) under the Self-Funded Dental Plan to Allied Administrators, Inc. and your claim is denied because you are not eligible for benefits.  If you appeal the claim denial, the Administrative Office will respond to your appeal.  If your appeal is received within 30 days prior to a Board meeting, your appeal will be considered.  Otherwise, your appeal will be considered at the next meeting of the Board or by the Appeals Committee, whichever comes first.

Generally, the Board meets no less frequently than quarterly.

Exhaustion of the Appeal Process

Under a Federal Law known as ERISA, a participant or beneficiary whose claim for benefits has been denied, may file suit against the Plan seeking the denied benefit. However, prior to filing such a suit, the appeal process under the Plan described above must be pursued and exhausted.  Thus, following any initial denial of benefits, if you disagree, it is important you file a timely appeal.  In all cases, your appeal must be filed no later than 180 days after the initial denial of your claim as received by you.  If you do not file an appeal within the required time frame, you will have failed to exhaust your appeal rights.  The Trustees may extend the 180 day limit upon your showing good cause for the delay, but to protect your rights you should file any appeal promptly after your receipt of the initial denial.

In the event that you disagree with the decision of the Trustees, you may submit the matter to arbitration in accordance with the Labor Arbitration Rules of the American Arbitration Association.  The questions for the arbitration shall be:

1. whether the Trustees were in error upon an issue of law;
2. whether the Trustees acted arbitrarily or capriciously in the exercise of their discretion; and
3. whether the Trustees finding of fact were supported by substantial evidence.

Following the arbitration, the Participant shall have the right to bring a civil action under Section 502 (a) of ERISA for a review of the arbitration’s findings on the three issues set forth in the preceding paragraph.  

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, 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.