15.16.1 MEDICAL BENEFIT CLAIM DETERMINATIONS AND APPEALS
The following procedures apply to any claim for medical benefits (including dental, vision and prescription drug).
Initial denial decisions and appeal decisions on review will be provided in a culturally and linguistically appropriate manner in a non-English language upon request, but only if you live in a county where 10 percent or more of the population is literate only in the same non-English language as determined by the applicable federal guidelines.
If the above percentage standard is met, the following three conditions will apply to claimants in such counties: oral language services such as a telephone hotline in the applicable non-English language will be available to answer questions and assist in filing claims and appeals; the Administrative Office will provide upon request a notice in the applicable non-English language; and will include the English version of all notices a statement in the applicable non-English language indicating how to access the language services.
The Plan ensures that claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of persons, including medical experts or review organizations involved in making decisions, and no hiring or retention decisions will be based upon the likelihood that the person will support a denial of benefits.
If the Administrative Office fails to adhere to all the requirements of the claims review process, you may be deemed to have exhausted the internal claims and appeal process and may submit a request for external review if applicable. A deemed exhaustion, however, does not occur if violations of the claims review process are de minimis violations that do not cause, and are not likely to cause, prejudice or harm to you so long as the violations were for good cause or due to matters beyond the control of the Plan and occurred in the context of an ongoing good faith exchange of information between you and the Administrative Office. You may request a written explanation of the violation, which must be provided within 10 days, including the bases for asserting that the violation should not cause the internal claims and appeals process to be deemed exhausted. In case there is a deemed exhaustion, you may also be entitled to remedies under Section 502 of ERISA by filing a case in court. Unless otherwise specified herein, you are required to exhaust the internal claim and appeal process before filing a request for external review or filing a lawsuit.
18.104.22.168 Timing of Initial Determination – Medical Benefit Claims After Service or Treatment
If your claim for a benefit does not require pre-approval in advance of receiving medical care, written notice of a denial will generally be provided to you within a reasonable period of time, but no later than 30 days after receipt of your claim by the Plan. If matters beyond the control of the Plan so require, one 15-day extension oftime for processing the claim beyond the initial 30 days may be taken. A written notice of the extension will be furnished to you before the end of the initial 30-day period. An extension notice will explain the reasons for the extension and the expected date of a decision.
If an extension is required because you have not provided the information necessary to decide your claim, the notice of extension will specifically describe the required information, and the time period for processing your claim will not run from the date of such notice until the earlier of 1) the date the Plan receives your response to a request for additional information or 2) the date set by the Plan for your requested response (at least 45 days from the date of the request).
22.214.171.124 Timing of Determination – Concurrent Care Medical Decision
- 126.96.36.199.1 Reduction or termination of ongoing course of treatment
If the Plan has previously approved an ongoing course of treatment to be provided over a period of time or a number of treatments, notice of any later decision to reduce or terminate the ongoing course of treatment (other than by Plan amendment or termination) shall be treated as an adverse benefit determination that you can appeal. Such notice will be provided to you sufficiently in advance of the reduction or termination to allow you to appeal and receive a determination on appeal before the treatment is reduced or terminated, so that generally your benefits for an ongoing course of treatment would continue pending an appeal.
- 188.8.131.52.2 Extension of ongoing course of treatment involving urgent care If your request that the Plan extend an ongoing course of treatment beyond the previously approved period of time or number of treatments involves urgent care, you will be notified of the decision by the Plan within 24 hours after its receipt of the request, provided the request is received at least 24 hours prior to the expiration of the pre-approved period of time or number of treatments.
184.108.40.206 Contents of Initial Denial – Medical Benefit Claims
If your claim is denied, in whole or in part, you will be notified in writing by the Plan. The written notice will include the following:
- the specific reason or reasons for the denial;
- references to the specific Plan provisions on which the denial is based;
- a description of any additional material or information necessary in order for you to perfect the claim, and an explanation of why such material or information is needed;
- an explanation of the Plan’s review procedure for denied claims, including the applicable time limits for submitting your claim for review (claims involving urgent care will have a description of expedited appeal procedures);
- a statement of your right to bring a civil action under Section 502(a) of ERISA if your claim is denied on appeal;
- a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in deciding your claim for benefits, or a statement that such was relied upon and a copy will be provided free of charge upon request;
- if the decision was based on a medical necessity or experimental treatment or other similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying Plan terms to your medical circumstances, or a statement that an explanation will be provided free of charge upon request;
- information sufficient to identify the claim involved, including the date of service, the health care provider, the claim amount (if applicable), and a statement describing the availability, upon request, of the diagnosis code and treatment code and their corresponding meanings;
- the specific reason or reasons for the denial including, to the extent applicable, the denial code and its corresponding meaning and a description of the Plan’s standard, if any, that was used in denying the claim
- an explanation of the Plan’s review procedure, including both internal appeal and external review processes, and information regarding how to initiate an appeal; and
- the availability of, and contact information for, any applicable office of health insurance consumer ombudsman established under the Public Health Services Act Section 2793 to assist individuals with the internal and external claims and appeals process.
220.127.116.11 Appeal Procedure for Denied Claim
If you wish to appeal a denial of a claim, you or your authorized representative must file a written appeal with the Plan Administrator within 180 days after receiving notice of denial, unless your claim concerns the reduction or termination of a previously approved ongoing course of treatment. In that case, you must file a written appeal within a shorter time period that permits the Plan Administrator to issue an appeal decision before the treatment is reduced or terminated. A denial of a claim includes a denial in whole or in part, and for purposes of appeal rights, includes a rescission of coverage whether or not the rescission has an adverse impact on any particular benefit at that time. You or your authorized representative may submit a written statement, documents, records, and other information. You may also, free of charge upon request, have reasonable access to and copies of Relevant Documents. The review will consider all statements, documents, and other information submitted by you or your authorized representative, whether or not such information was submitted or considered under the initial denial decision. Claim determinations are made in accordance with Plan documents and, where appropriate, Plan provisions are applied consistently to similarly situated claimants. In addition:
- the appeal decision will not defer to the initial decision denying your claim and will be made by a plan fiduciary who is not a person who made the initial decision, nor a subordinate of such person;
- if the initial denial decision was based in whole or in part on a medical judgment, the plan fiduciary will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment;
- any health care professional engaged for such consultation will not be a person consulted in the initial decision, nor a subordinate of any such person;
- any medical or vocational expert whose advice was obtained in connection with the decision to deny your claim will be identified upon request, whether or not the advice was relied upon;
- if your claim involves urgent care, your request for an appeal may be submitted orally or in writing, and all necessary information, including the appeal decision, is to be transmitted between the Plan and you by telephone, facsimile, or other similarly expeditious method;
- you will be provided, free of charge, any new or additional evidence considered, relied upon, or generated by the Plan or at the direction of the Plan in connection with the claim, and such information will be provided as soon as possible and sufficiently in advance of the date of the final internal appeal decision is required to be issued to provide a reasonable opportunity for you to respond prior to that date; and
- if a final internal appeal decision is based on new or additional rationale, you will be provided, free of charge, with the rationale as soon as possible and sufficiently in advance of the date on which the final internal appeal decision is required to be issued to provide a reasonable opportunity for you to respond prior to that date.
The Administrative Committee of the Board of Trustees reviews appeals of denied claims and makes final determinations. The Administrative Committee has full discretionary authority, including power to administer, construe and interpret the terms and provisions of the Plan, SPD and Trust Agreement and to determine eligibility for benefits under the Plan.
18.104.22.168 Timing of Appeal Decision – Medical Benefit Claims After Service or Treatment
Your appeal generally will be addressed at the next regularly scheduled quarterly meeting of the Administrative Committee after an appeal is received. If, however, your appeal is received within 30 days prior to such a meeting, it will be considered by the second regularly scheduled quarterly meeting after it is received. In addition, if special circumstances require an extension of time for processing your appeal, a decision will be rendered no later than the third regularly scheduled quarterly meeting after your appeal is received. Written notice of any extension of time will be sent before it commences explaining the reason for the extension and the expected date of the appeal determination. Notice of the appeal decision will be provided not later than five days after the decision is made.
If an extension is required because you have not provided the information necessary to decide your claim, the time period for processing your claim will not run from the date of notice of an extension until the earlier of 1) the date the Plan receives your response to a request for additional information or 2) the date set by the Plan for your requested response (at least 45 days from the date of the request).
22.214.171.124 Hearing on Appeal
Within a reasonable time after receipt of the request for review, you will be notified of the date, time and place of the appeal hearing by regular mail addressed to your address as shown on the request for review. You may request to be present at the hearing before the Administrative Committee. You may be represented at the hearing by an attorney or any other representative of your choosing. The proceedings at the hearing may be recorded by a method determined by the Committee. In conducting the hearing, the Committee shall not be bound by the usual common law or statutory rules of evidence. Copies will be made of all statements, documents, and records that you or your authorized representative introduces at the hearing and all other Relevant Documents. This information will be attached to the record of the hearing, and made a part thereof.
126.96.36.199 Contents of Appeal Decision – Medical Benefit Claims
If you appeal a denied claim, the decision on review will be in writing and will include the following information:
- the specific reason or reasons for the decision;
- reference to the specific Plan provisions on which the decision is based;
- a statement of your right to receive, upon request free of charge, reasonable access to and copies of allRelevant Documents;
- a statement of your right to bring a civil action under Section 502(a) of ERISA;
- a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in deciding your claim for benefits on review, or a statement that such was relied upon and that a copy will be provided free of charge upon request;
- if the decision on review was based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying plan terms to your medical circumstances, or a statement that an explanation will be provided free of charge upon request;
- the following statement: “You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U. S. Department of Labor Office and your State insurance regulatory agency;”
- information sufficient to identify the claim involved, including the date of service, the health care provider, the claim amount (if applicable), and a statement describing the availability, upon request; of the diagnosis code and treatment code and their corresponding meanings;
- the specific reason or reasons for the decision including, to the extent applicable, the denial code and its corresponding meaning and a description of the Plan’s standard, if any, that was used in denying the claim that includes a discussion of the decision;
- an explanation of the Plan’s available external review process for denied claim, including information regarding how to initiate the external review and the applicable time limits; and
- the availability of, and contact information for, any applicable office of health insurance consumer ombudsman established under the Public Health Services Act Section 2793 to assist individuals with the internal and external claims and appeals process.
188.8.131.52 Relevant Documents
Relevant Document means any document, record or other information that:
- was relied upon in making a decision to deny benefits;
- was submitted, considered, or generated in the course of making the decision to deny benefits, whether or not it was relied upon in making the decision to deny benefits;
- demonstrates compliance with any administrative processes and safeguards designed to confirm that the benefit determination was in accord with the plan and that plan provisions, where appropriate, have been applied consistently regarding similarly situated individuals; or
- constitutes a statement of policy or guidance with respect to the plan concerning a denied treatment option or benefit for the claimant’s diagnosis, without regard to whether such advice or statement was relied upon in making the decision to deny benefits.
184.108.40.206 Voluntary External Review for Medical Claims
If your claim for medical benefits has been denied under the Plan’s internal appeal process (or you are deemed to have exhausted the internal appeal process), you may have the option to file a voluntary appeal for external review by an independent review organization. You may submit a request for external review of a medical claim denial only if the denial involves: 1) medical judgment (including but not limited to requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit; or a determination that treatment is experimental or investigational), as determined by the external reviewer; or 2) a rescission of coverage, regardless whether the rescission has any effect on a benefit at that time. Denial determinations on the basis that you failed to meet enrollment or eligibility requirements under the Plan are not subject to review by the external review process.
The request must be filed with the Administrative Office within four months after the date of receipt of the denial decision. If there is no corresponding date four months after the date of receipt of the denial decision, the request must be filed by the first day of the fifth month following the receipt of the denial decision. If the last filing date falls on a weekend or Federal holiday, the filing date is extended to the next week that is not a weekend or Federal holiday.
Within five business days following the date of receipt of the external review request, the Administrative Office will complete a preliminary review of the request to determine whether:
- the claim was covered under the Plan at the time the health care item or service was requested or, in the case of retrospective review, was covered under the Plan at the time the health care item or service was provided;
- the denial decision does not relate to the claimant’s failure to meet enrollment and eligibility requirements under the terms of the Plan;
- you have exhausted the Plan’s internal review process unless you are not required to exhaust the internal appeals process under the applicable final regulations; and
- you have provided all the information and forms required to process an external review.
Within one business day after completing the preliminary review, the Administrative Office shall issue a written notice to you as to whether your claim is eligible for external review. If your request is complete but not eligible, the notice will include the reasons for its ineligibility and contact information for the Employee Benefits Security Administration, toll-free number 866-444-EBSA (3272), at the Department of Labor. If the request is not complete, the notice will describe the information or materials needed to make the request complete. You will be allowed to perfect the request for external review within the four-month filing period or within the 48-hour period following receipt of the notice. Whichever is later.
If your request for external review is complete and eligible, it will be assigned to an independent review organization (“IRO”) that has been accredited by URAC or a similar nationally-recognized accrediting organization to conduct the external review. The Administrative Office has contracted with IROs and uses unbiased methods for selecting the IRO for your claim.
The assigned IRO will utilize legal experts where appropriate to make coverage determinations under the Plan. It will provide you a written notice of your request’s eligibility and acceptance for external review which will include a statement that you may submit, within ten business days after receipt of the notice, additional information that the IRO must consider when conducting its review. The IRO is not required to, but may consider, information submitted after ten business days. Within five business days after assignment of the IRO, the Plan shall provide the IRO the documents and information considered in making the denial decision. If the Plan fails to timely provide the documents and information, the IRO may terminate the external review and make a decision to reverse the denial decision. The IRO shall notify you and the Plan of its decision within one business day after it is made. The IRO shall forward information submitted by you to the Plan within one business day. Upon receipt of the information, the Administrative Office may reconsider its denial decision
and if it decides to reverse its decision, notify you and the IRO within one business day after making such a decision. The IRO shall terminate its external review upon receipt of such notice.
The IRO will review your claim de novo and not be bound by any decisions or conclusions reached during the Plan’s internal claim and appeal process. In addition to the documents and information provided, the IRO to the extent such information is available and the IRO considers them appropriate, will consider the following in its decision:
- your medical records;
- the attending health care professional’s recommendation;
- reports from appropriate health care professionals and documents submitted by the Plan, you and your treating provider;
- the terms of the Plan;
- appropriate practice guidelines, which must include applicable evidence-based standards and may include other practice guidelines developed by the Federal government, national or professional medical societies, boards, and associations;
- applicable clinical review criteria developed and used by the Plan, unless the criteria are inconsistent with terms of the Plan or applicable law; and
- the opinion of the IRO’s clinical reviewer after considering documents and information to the extent they are available and the clinical reviewer considers them appropriate.
The IRO shall provide written notice of the final external review decision to you and the Plan within 45 days after the IRO receives the request for external review. The IRO’s decision shall include the following:
- a general description of the reason for the request for external review, including information sufficient to identify the claim (including the dates of service, health care provider, claim amount if applicable, the diagnosis and treatment codes and their corresponding meanings, and the reason for the previous denial);
- the date the IRO received the assignment to conduct the external review and the date of the IRO decision;
- references to the evidence or documentation, including the specific coverage provisions and evidencebased standards, considered in reaching its decision;
- a discussion of the principal reasons for its decision, including the rationale for its decision and any evidence-based standards that were relied on in making its decision;
- a statement that the determination is binding except to the extent that other remedies may be available under State or Federal law to you or the Plan;
- a statement that judicial review may be available to you; and
- current contact information, including phone number, for any applicable office of health insurance consumer assistance or ombudsman established under the Public Health Services Act Section 2793.
After a final external review decision, the IRO shall maintain records of the claim and notices for six years. Such records are available for examination by you, the Plan or applicable governmental oversight agencies upon request, except where such disclosures would violate applicable privacy laws.
Upon receipt of a final external review decision reversing a denial decision, the Plan shall immediately provide coverage or payment for the claim.
220.127.116.11 Expedited External Review Process for Denied Claims
If your claim is eligible for the external review process, you may request an expedited external review if:
- an initial denial involves a medical condition for which the timeframe for completing an expedited internal appeal would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function, and you have filed a request for an expedited internal appeal; or
- a final internal appeal decision involves a medical condition where the timelines for completion of a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function, or the appeal decision concerns an admission, availability of care, continued stay, or health care item or service for which you have received emergency services but have not been discharged from a facility.
Immediately upon receipt of a request for expedited external review, the Administrative Office shall determine whether the request meets the reviewability standards set for preliminary reviews under the Standard External Review Process discussed above. The Administrative Office shall immediately send you a notice that complies with the requirements for standard external reviews as to whether your request for an expedited external review is eligible.
If your request for an expedited external review is complete and eligible, it will be assigned to an IRO. The Administrative Office shall provide all necessary documents and information considered in making its denial decision to the IRO electronically or by telephone or facsimile or other available expeditious method. The IRO, to the extent information or documents are available and the IRO considers them appropriate, shall consider the documents and information described above for standard external reviews. The IRO shall review the claim de novo and is not bound by any decision or conclusions reached during the Plan’s internal claims and appeal process.
The IRO shall provide a notice of its final expedited external review decision in accordance with the requirements for standard external review decisions as expeditiously as your medical condition or circumstances require, but no later than 72 hours after the IRO receives the request for an expedited external review. If the notice is not in writing, within 48 hours of the notice, the IRO shall provide written confirmation of the decision to you and the Plan.