CLAIMS PROCEDURES

NOTICE OF CLAIM: Written notice of claim must be given to the Third Party Administrator within thirty (30) days after the loss occurs. If this is not possible, written notice must be given as soon as is reasonably possible.

CLAIM: A claim is a complete insurance billing including diagnosis and procedure codes. If your plan requires preauthorization for the service in question, a request by a claimant or a health care professional for preauthorization is considered a claim, however, once the service is performed a complete insurance billing including diagnosis and procedure codes must be submitted for processing. Claims are divided into four (4) categories:

  1. pre-service claims: Services requiring preapproval by the plan;
  2. urgent care claims: A pre-service claim where the claimant's life, health or ability to regain maximum function is seriously jeopardized;
  3. post-service claims: A claim submitted for reimbursement after the services have been provided;
  4. concurrent care decisions: A special category of decisions where the Plan reverses its preapproval of a series of medical Treatments before the Treatments are completed.

PROOF OF LOSS: The Third Party Administrator must be given written proof of loss within ninety (90) days after the date of such loss. If it was not reasonably possible to give written proof in the time required, the claim will not be reduced or denied solely for this reason if proof is filed as soon as reasonably possible. In any event, proof of loss must be given no later than one (1) year from date of loss unless the claimant was legally incapacitated. The Third Party Administrator may require, as part of the proof, authorization to obtain medical and non-medical information. (Medicare/Medicaid claims payable as mandated by current federal regulations as long as this Plan is still in force at the time the claim and any required information is received.)

LEGAL ACTIONS: No legal action to recover any benefits may be brought before sixty (60) days after the required written proof of loss has been given. No legal action may be brought more than one (1) years after written proof of loss is required to be given. (The one (1)-year limitation in the prior sentence, however, does not apply to an action governed by 29 U.S.C. §1113.)

PHYSICAL EXAMINATIONS: The Third Party Administrator, at its expense, may have a Covered Person examined as often as reasonably necessary while any claim is pending.

INITIAL BENEFIT DETERMINATION:

URGENT CARE CLAIMS: If your Plan requires pre-approval on urgent care claims, an initial claim decision must be made in seventy-two (72) hours or less with no extensions. *Notice of incompleteness must be filed within twenty-four (24) hours of receipt of an incomplete claim.
PRE-SERVICE CLAIMS: If your Plan requires pre-approval on any other services, an initial claim decision must be made in fifteen (15) days or less. The Plan may have a fifteen (15)-day extension with notice if the Plan Administrator determines that such an extension is necessary for reasons beyond the control of the Plan. *Notice of incompleteness must be filed within five (5) days of receipt of an incomplete claim.
POST-SERVICE CLAIM: An initial decision must me made in thirty (30) days or less. The Plan may have a fifteen (15)-day extension if the Plan Administrator determines that such an extension is necessary for reasons beyond the control of the Plan.
CONCURRENT CARE DECISION: Notice of termination or reduction of previously granted benefits must be given sufficiently in advance of the termination or reduction so as to allow the claimant time to appeal the denial before the termination or reduction takes effect.
SHORT-TERM DISABILITY CLAIMS: If your Plan includes short-term disability coverage, an initial decision must be made within forty-five (45) days of receipt of a claim. The Plan may extend that decision-making period for an additional thirty (30) days for reasons beyond the control of the Plan. If, after extending the time period for a first period of thirty (30) days, the Plan administrator determines that it will still be unable, for reasons beyond the control of the Plan, to make a decision within the extension period, the Plan may extend the decision-making for a second thirty (30)-day period. The disability claimant will be provided with an extension notice that details the reasons for the delay.

*An urgent care or preservice claim requiring a notice is triggered only by a communication from a claimant or a health care professional representing the claimant that specifies the identity of the claimant, a specific medical condition or symptom, and a specific Treatment, service or product for which approval is requested and the request is received by the claims department. A notice of incomplete claim may be provided orally to the claimant or health care provider unless the claimant or health care provider request a written notice.

RIGHTS OF REVIEW AND APPEAL: If a claim is partially or wholly denied for any reason, the Covered Employee will be notified in writing. The written denial will give specific reasons for the denial with reference to the Plan provisions, a description of any additional information required from the claimant, a statement of the claimant's right to obtain relevant documents and other information, a description of any additional required or voluntary appeals and a statement of the claimant's right to sue, a statement that a copy of "internal rules or guidelines" relied on in denying the claim may be obtained without cost upon request, and a statement that a written explanation of any "scientific or clinical judgment" relied on in denying the claim may be obtained without cost upon request.

If a claim is not processed within ninety (90) days of receipt by the Third Party Administrator, a Covered Employee may proceed to the Review Procedure, as if the claim had been denied.

REVIEW AND APPEAL PROCEDURES: A Covered Employee, or the Covered Employee's representative, may request a review of the claim denial by making written request to the Third Party Administrator within one hundred eighty (180) days of receipt of an adverse benefit determination. This written notice for review should:

  1. state the reason why the Covered Person feels the claims should not have been denied; and
  2. include any additional documentation which the Covered Person feels supports the claim. The Covered Employee may review pertinent documents and submit additional questions or comments for consideration.

DECISION ON REVIEW: The Third Party Administrator will make a full and fair review of the claim and give final written notice of its decision within thirty (30) days after the request is received for a pre-service claim denial or sixty (60) days after the request is received for a post-service claim denial. The written notice on the review will include specific reasons for the decision and include references to the Plan provisions on which the decision was based. The review will not be completed by the same individual or a subordinate of the individual who made the initial decision. If the Covered Employee does not agree with the review decision, the Covered Employee, or the Covered Employee's representative, may notify the Third Party Administrator in writing within the same thirty (30) days for a pre-service claim denial or sixty (60) days for a post-service claim denial. This thirty (30) or sixty (60) day limit is from the date of the initial denial. The Third Party Administrator will then retain an Independent Consultant of our choice whose decision will be based on clinical evidence and medical history and will be the final decision.

(In the case of conflicting information, your Schedule of Benefits takes precedence.)

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