
* Administering Health, Pension and Vacation Benefits For the Men and Women Who Help Build the Southwest *
Applicable to Medical Benefits and Eligibility Determinations Only—for dental and vision claims and appeals procedures, refer to the Disclosure Booklets issued by those organizations.
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 claim form may be obtained from the Administrative Office or 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.
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 |
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 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 medical benefits. For other benefits, 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 Anthem Claims Administrator 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
For pre-service claims, you will receive notice of the determination orally or in writing even when the claim is approved.
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? |
|
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. |
|
Time limits and notification mechanism for the Plan’s response to an appeal. |
Urgent Claims Pre-Service Claims Post-Service Claims |
What the Plan must provide if the appeal is denied. |
You may request and receive at no charge:
|
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? |
|
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. |
|
Time limits for the IRO’s review. |
|
An expedited external review may be requested if:
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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