Claims And Appeals Procedures

Applicable to Fee-For-Service Medical Benefits and Eligibility Determinations Only—for HMO, dental and vision claims and appeals procedures, refer to the Disclosure Booklets issued by those organizations.

Claims Procedures

These are the procedures for filing claims for benefits from the Southwest Carpenters Health and Welfare Trust (the Plan) effective January 1, 2015. This section also describes the procedure for you to follow if your claim is denied in whole or in part and you wish to appeal the decision.

Benefits are paid only if a claim is filed within 12 months from the date Covered Expenses were incurred for a Non-Network Provider. In-Network Providers must file a claim within the time frame required by their network contract (e.g., 180 days) but in no event later than 12 months from the date Covered Expenses were incurred. In-Network Providers will generally submit claims on your behalf. 

If you receive services from Non-Network Providers, you may be required to file a claim for benefits yourself with the third party claims administrator (Anthem Blue Cross). A standard claiform may be obtainefrom the AdministrativOfficor from the Plan’s website.

Simple inquiries about the Plan’s provisions that are unrelated to any specific benefit claim will not be treated as a claim for benefits. For example, calling the Administrative Office and asking whether the Fund covers speech therapy is not a claim for benefits.

A request for pre-authorization regarding the Plan’s coverage of a medical treatment, service or supply that your physician has recommended is not a “claim” under these procedures unless the Plan requires you to obtain pre-authorization. For example, a request for pre-authorization of an appendectomy is not a mandatory condition for receiving benefits and will not be treated as a claim for benefits. See the Summary Plan Description (SPD) discussion of the pre-authorization requirements.

According to federal regulations, a “claim” does not include an attempt to fill a prescription at a retail pharmacy in the Express Scripts network. On the other hand, a “claim” does include attempts to have a prescription filled through the Express Scripts mail order program. However, in either case, if your request for a prescription is denied, in whole or in part, you may file an appeal by using the procedures described below.

Requests for determination of whether a person is eligible for benefits will not be considered a claim under these procedures unless a specific claim for benefits is denied for lack of eligibility.

Claims should be filed within 90 days following the date the charges were incurred. Failure to file claims within the time required shall not invalidate or reduce any claim if it was not reasonably possible to file the claim within such time. However, in that case, the claim must be submitted as soon as reasonably possible and in no event later than one year from the date the charges were incurred.

An authorized representative, such as your spouse, may complete the claim form for you if you are unable to complete the form yourself and have previously designated the individual to act on your behalf. A form can be obtained from the Administrative Office to designate an authorized representative. The Plan may request additional information to verify that this person is authorized to act on your behalf. Even if you have designated an authorized representative to act on your behalf, you must personally sign a claim form and file it with the Administrative Office at least annually.

The claims procedures for fee-for-service medical benefits will vary depending on the type of claim. There are four different types of claims. The amount of time we have to make a determination (approval or denial) depends on the type of claim you are filing.

  • Pre-service Claims
    A Pre-service Claim is a claim for Plan benefits for which the Plan requires Preauthorization (in whole or in part) before you obtain the service or supply in order to receive benefits under the Plan.
  • Post-service Claims
    A Post-service Claim is any claim for Plan benefits that are not Pre-service claims. You are filing a Post-service claim if you have already received the service or supply.
  • Urgent Claims
    An Urgent Claim is any claim for care or treatment which, if the time periods for making Pre-service claim decisions were applied, would:
    • Seriously jeopardize your life or health or your ability to regain maximum function; or
    • Subject you to severe pain that cannot be controlled without the care or treatment for which you are seeking approval, in the opinion of a Provider with knowledge of your condition.
  • Concurrent Care Claims
    A Concurrent Care Claim is a claim that is reconsidered after it is initially approved for an ongoing course of treatment, to be provided over a period of time or number of treatments, and the reconsideration results in a reduction or termination of benefits. A Concurrent Care Claim is also any request by you to extend the course of treatment that involves urgent care.

There are certain time frames in which we must provide notice of a claim determination. Once we receive a claim, a notice (Explanation of Benefits) is sent to you and your healthcare Provider (if applicable) to explain if we allowed or denied your claim. Notice of claim determination must be provided as described in the following chart.

Type of Claim

Time of Notice of Claim Determination

Urgent Claim
See below for the note regarding Emergencies.

As soon as possible but not later than 72 hours after receipt of the claim.

If additional information is necessary, notice will be sent within 24 hours and the claimant will be provided at least 48 hours to respond. The claim determination will be made within 48 hours of when the additional information is received or the expiration of the time for the claimant to respond.

Concurrent Care Claim

Sufficiently in advance of the reduction or termination of benefits.

If the claim is a request for an extension of benefits then the determination will be made within 24 hours after receipt of the request.

Pre-service Claim

Within a reasonable period of time appropriate for the medical circumstances but not later than 15 days after receipt of the claim.

If an extension is necessary, notice will be sent within the initial 15 day period, stating the reason for the extension and the date by which we expect a to render a decision. This date will be no more than 15 days after the end of the initial 15 day period, unless the extension is necessary due to a failure of the claimant to submit the information necessary to decide the claim.

Post-service Claim

Within a reasonable period of time but no later than 30 days after receipt.

If an extension is necessary, notice will be sent within the initial 30 day period, stating the reason for the extension and the date by which we expect to render a decision. This date will be no more than 15 days after the end of the initial 30 day period, unless the extension is necessary due to a failure of the claimant to submit the information necessary to decide the claim.

Extension Request for Post-Service or Pre-Service Claims

If an extension is necessary because the claimant has failed to provide sufficient information to decide the claim, written notice will be given describing what information is required. The claimant will be given 45 days to provide the additional information.

The claim determination deadline will be suspended from the time the notice of extension is sent until the earlier of:

  • The date the Plan receives the additional information; or
  • The date stated in the notice.

The claim determination will be rendered within 15 days of the earlier of these two dates, and a written notice of the claim determination will be sent to the claimant.

Note regarding Emergencies: An Emergency does not require pre-authorization, just notice to Anthem. “Emergency” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possess an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in various types of serious harm.

Note regarding PRE-AUTHORIZATION: Pre-authorization is required for some benefits under the Fee-for-Service Medical Option. For other benefits under the Fee-For-Service Medical Option, pre-authorization is recommended because the Claims Administrator can direct you to providers who will save you money. For pre-authorization of services, contact the Claims Administrator Anthem Blue Cross at (800) 274-7767.

See the Summary Plan Description for the Active Plan for further information about when you are required to obtain pre-authorization of services and when pre-authorization is voluntary, but recommended.

You will be provided with written notice of a denial of a claim, whether your claim is denied in whole or in part. This notice will include

  • Information sufficient to identify the claim involved (e.g. date of service, health care provider, claim amount if applicable);
  • A statement that, upon request and free of charge, the diagnosis code and/or treatment code, and their corresponding meanings, will be provided. However, a request for this information will not be treated as a request for an internal appeal or an external review;
  • The specific reason(s) for the determination, including the denial code and its corresponding meaning and a discussion of the decision, as well as any Plan standards used in denying the claim,
  • Reference to the specific Plan provision(s) on which the determination is based,
  • A description of any additional material or information necessary if you want a further review of the claim and an explanation of why the material or information is necessary,
  • An explanation of the Plan’s 1st and 2nd level appeal and the external review process, along with any time limits and information regarding how to initiate the next level of review,
  • A statement of your right to bring a civil action under ERISA Section 502(a) following an adverse appeal determination,
  • If an internal rule, guideline, protocol or other similar criterion was relied upon in deciding your claim, either a copy of the rule, guideline, protocol or other similar criterion or a statement that it was relied upon in deciding your claim and that it is available upon request at no charge, 
  • If the determination was based on not being Medically Necessary or the treatment’s being Experimental or investigational or other similar exclusion, an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your claim, or a statement that it is available upon request at no charge, and
  • Disclosure of the availability of, and contact information for, any applicable ombudsman established under the Public Health Services Act to assist individuals with internal claims and appeals and external review processes.

For pre-service claims, you will receive notice of the determination orally or in writing even when the claim is approved.

Appeals Procedures

If your claim is denied in whole or in part, or if you disagree with the decision made on a claim, you may ask for a review. The following tables contain a summary of the procedures for appealing a denied claim. Further details on the appeals process are contained in the Summary Plan Description for Active Carpenters.

Your time limit for appealing an Adverse Benefit

Within 180 days of receipt of the Adverse Benefit Determination

Who can submit an appeal of an Adverse Benefit

Determination?

  •  You
  •  Your authorized representative; or
  •  A Provider for Urgent Claims

How you may submit an appeal?

Urgent Claims—orally or in writing

Pre-service Claims—in writing

Post-service Claims—in writing

Where should you submit an appeal?

First level appeal requests: To the Claims Administrator, Anthem, who made the determination on the claim.

Second level appeal requests: To the Carpenters Southwest Administrative Office.

What the claimant may submit for an appeal.

Written information relating to the claim.

The Plan’s obligation when considering an appeal.

  • Take into account all information submitted by you or your authorized representative, even if the information was not included in the original claim.
  • Ensure that the initial denial will not be given consideration.
  • In appeals based in whole or in part on a medical judgment, including possible
  • Experimental treatment, assure that the reviewer is a health care professional with appropriate training and experience.

Time limits and notification mechanism for the Plan’s response to an appeal.

Urgent Claims
No later than 72 hours after the appeal. Plans must transmit all necessary information by phone, fax, or similarly expeditious method.

Pre-Service Claims
No later than 15 days after the receipt of the appeal for first and second level appeal requests.

Post-Service Claims
No later than 30 days after the receipt of the appeal for first level appeal to Claims Administrator (Anthem). No later than 5 days after the quarterly meeting of the Appeals Committee for second level appeal.

What the Plan must provide if the appeal is denied.

  • Specific reasons for the denial.
  • Reference to the relevant Plan provision.
  • A statement that you can receive, free of charge, all relevant information.
  • A description of the voluntary appeal procedures the Plan offers.
  • A statement of your right to bring civil action following a final internal Adverse Benefit Determination.
  • Notification that voluntary alternative dispute resolution options may be available and that more information is available from the U.S. Department of Labor.

You may request and receive at no charge:

  • A copy of the internal rule, guideline, protocol or similar criterion considered in making the decision; and/or
  • An explanation of the scientific or clinical judgment if the decision is based on Medical Necessity or Experimental treatment.
Your time limit for submitting an external review Within 4 months of the receipt of an Adverse Benefit Determination or final internal Adverse Benefit Determination.
Who can request an external review?
  •  You; or
  •  Your authorized representative.
How you may submit a request. In writing.
Where should you submit the request? The Carpenters Southwest Administrative Office.
Time limits and notification mechanism for the Plan’s response to the review request.
  • Within 5 business days following the receipt of the request, the Fund must complete a preliminary review to determine if the request is eligible for review.
  • Within 1 business day, the Fund must send written notice of the preliminary review determination.
  • If the request is complete but not eligible for review, the notification shall include an explanation and contact information for any applicable office of health insurance consumer assistance.
  • If the request is not complete, the notification will describe what is needed to make the request complete. In addition the Fund shall allow a claimant to perfect the request within the 4 month filing period or within the 48 hour period following the receipt of the notification, whichever is later.
Time limits for the IRO’s review.
  • The IRO will notify you in writing of the acceptance of the review request. If the IRO requires additional information, the additional information must be received within 10 business days following their request for the information.
  • The IRO must notify you of the final external review decision within 45 days after the IRO receives the request for the review.

An expedited external review may be requested if:

  • An Adverse Benefit Determination involves a medical condition for which the timeframe for completion of an expedited internal appeal would seriously jeopardize the life or health of the claimant or would jeopardize the claimant’s ability to regain maximum function and the claimant has requested an expedited internal appeal; or
  • A final internal Adverse Benefit Determination involves a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the claimant or would jeopardize the claimant’s ability to regain maximum function, or if the final internal Adverse Benefit Determination concerns an admission, availability of care, continued stay, or health care item or service for which the claimant received Emergency services, but has not been discharged from a facility.

Expedited external review procedures are the same as external review request procedures but are performed as expeditiously as possible, but in no event more than 72 hours after the IRO receives the request for an expedited external review. If the notice is not in writing, then within 48 hours after providing the decision the IRO must provide written confirmation.

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