CLAIM REVIEW / CLAIM APPEAL PROCEDURE
HERE IS YOUR PROCEDURE FOR HAVING A CLAIM REVIEWED
(Claims Review/Claim Appeal Procedure for Claims filed on or after January 1,
2003.)
a. Statement of Intent.
The Trustees intend to establish and to maintain reasonable claim procedures as
required by law.
b. Precertification or
Preauthorization Contact. A Claimant who wishes to precertify or
preauthorize a form of treatment as required by this Plan should contact
Independence Blue Cross ("IBC") at the telephone number found on the reverse
side of the member's identification card.
c. Authorized
Representative. A Claimant for benefits under this Pan may appoint an
authorized representative to act on the Claimant's behalf in pursuing a claim or
an appeal from an adverse benefit determination. Any person who wishes to be
recognized by the Plan as the authorized representative of a Claimant should
contact the Fund office.
d. Filing of Claims.
Any participant, former participant, dependent or beneficiary (designated or
contingent) under the Plan ("Claimant"), may file a written claim for benefits
with the Trustees through the Fund office.
e. Notification on Denial
of Claim. In the event of an adverse benefit determination, the Plan or IBC
will send the Claimant a written notification containing specific reasons for
the adverse benefit determination. The written notification will contain
specific reference to pertinent Plan provisions on which the adverse benefit
determination is based. In addition, the written notification will contain a
description of any additional material or information necessary for the Claimant
to perfect the claim, as well as an explanation of why such material or
information is necessary. Furthermore, the notification shall provide
appropriate information as to the steps to be taken if the Claimant wishes to
seek review of the adverse benefit determination.
f. Time Frames. The
following time frames will apply to benefit determinations by the Plan:
(1) Urgent Care Claims.
In the case of a claim involving urgent care, the Plan shall notify the Claimant
of the Plan's benefit determination (whether adverse or not) as soon as
possible, taking into account the medical exigencies, but not later than 72
hours after receipt of the claim by the Plan, unless the Claimant has failed to
provide sufficient information to determine whether, or to what extent, benefits
are covered or payable under the Plan. In the case of such a failure, the Plan
or IBC shall notify the Claimant as soon as possible, but not later than 24
hours after receipt of the claim by the Plan, of specific information necessary
to complete the claim. The Claimant shall be afforded a reasonable amount of
time, taking into account the circumstances, but not less than 48 hours, to
provide the specified information. Notification of any adverse benefit
determination pursuant to this paragraph shall be made in accordance with
Paragraph e of this section. The Plan or IBC shall notify the Claimant of the
Plan's benefit determination as soon as possible, but in no case later than 48
hours after the earlier of the Plan's receipt of the specified information, or
the end of the period afforded the Claimant to provide the specified additional
information.
(2) Concurrent Care
Decision. If the Plan or IBC has approved an ongoing course of treatment to
be provided over a period of time or a number of treatments --
(a) Any reduction or termination by the Plan or IBC of such course of
treatment (other than by Plan amendment or termination) before the end of such
period of time or number of treatments shall constitute an adverse benefit
determination. The Plan or IBC shall notify the Claimant in accordance with
Paragraph e of this section, of the adverse benefit determination at a time
sufficiently in advance of the reduction or termination to allow the Claimant to
appeal and to obtain a determination on review that the adverse benefit
determination before the benefit is reduced or terminated.
(b) Any request by a Claimant to extend the course of treatment
beyond the period of time or number of treatments concerning a claim involving
urgent care shall be decided as soon as possible, taking into account medical
exigencies, and the Plan or IBC shall notify the Claimant of the benefit
determination, whether adverse or not, within 24 hours after receipt of the
claim by the Plan, provided that any such claim is made to the Plan at least 24
hours prior to the expiration of the prescribed period of time or number of
treatments. Notification of any adverse benefit determination concerning a
request to extend the course of treatment, whether involving urgent care or not,
shall be made in accordance with Paragraph e of this section, and appeal shall
be governed by Paragraph g(5)(a), (b) or (c) of this section, as appropriate
(3) Pre-Service Claims. In the case of a pre-service claim, the
Plan or IBC shall notify the Claimant of the Plan's benefit determination
(whether adverse or not) within a reasonable period of time appropriate to the
medical circumstances, but not later than 15 days after receipt of the claim by
the Plan or IBC. This period may be extended one time by the Plan or IBC for up
to 15 days, provided the Plan or IBC both determines that such an extension is
necessary due to matters beyond the control of the Plan or IBC, and notifies the
Claimant prior to the expiration of the initial 15-day period of the
circumstances requiring the extension of time and the date by which the Plan or
IBC expects to render a decision. If such an extension is necessary due to a
failure of the Claimant to submit the information necessary to decide the claim,
the notice of extension shall specifically describe the required information,
and the Claimant shall be afforded at least 45 days from receipt of the notice
within which to provide this specified information. Notification of any adverse
benefit determination pursuant to this paragraph shall be made in accordance
with Paragraph e of this section.
(4) Post-Service Claims. In the case of a post-service claim,
the Plan shall notify the Claimant, in accordance with Paragraph e of this
section, of the Plan's adverse benefit determination within a reasonable period
of time, but not later than 30 days after receipt of the claim. This period may
be extended one time by the Plan or IBC for up to 15 days, provided that the
Plan or IBC both determines that such an extension is necessary due to matters
beyond the control of the Plan or IBC and notifies the Claimant, prior to the
expiration of the 30-day period, of the circumstances requiring the extension of
time and the date by which the Plan or IBC expects to render a decision. If
such an extension is necessary due to a failure of the Claimant to submit the
information necessary to decide the claim, the notice of extension shall
specifically describe the required information, and the Claimant shall be
afforded at least 45 days from receipt of the notice within which to provide the
specified information.
(5) Disability Claims. In the case of a claim for disability
benefits under this Plan, the Plan shall notify the Claimant, in accordance with
Paragraph e of this section, of the Plan's adverse benefit determination within
a reasonable period of time, but not later than 45 days after receipt of the
claim by the Plan. This period may be extended by the Plan for up to 30 days,
provided that the Plan both determines that such an extension is necessary due
to matters beyond the control of the Plan and notifies Claimant, prior to the
expiration of the initial 45-day period, of the circumstances requiring the
extension of time and the date by which the Plan expects to render a decision.
If, prior to the end of the first 30-day extension period, the Plan determines
that, due to matters beyond the control of the Plan, a decision cannot be
rendered within the extension period, the period for making the determination
may be extended for up to an additional 30 days, provided that the Plan notifies
the Claimant, prior to the expiration of the first 30-day extension period, of
the circumstances requiring the extension and the date as of which the Plan
expects to render a decision. In the case of any extension under this
paragraph, the notice of extension shall specifically explain the standards on
which entitlement to a benefit is based, the unresolved issues that prevent a
decision on the claim, and the additional information needed to resolve those
issues, and the Claimant shall be afforded at least 45 days within which to
provide the specified information.
g. Right of Review
(1) Full and Fair Review. A Claimant who receives an adverse
benefit determination with respect to any claim shall have the right to a full
and fair review of that determination as required by law. For purposes of this
Plan, an "adverse benefit determination" means any of the following: a denial,
reduction, or termination of, or a failure to provide or make payment (in whole
or in part) for a benefit, including any such denial, reduction, termination, or
failure to provide or make payment that is based on the determination of a
Claimant's eligibility to participate in the Plan, and including a failure to
provide or make payment (in whole or in part) for a benefit resulting from the
application of any utilization review as well as a failure to cover an item or
service for which benefits are otherwise provided because the service is
determined to be experimental or investigational or not medically necessary or
appropriate.
(2) Time Frame for Seeking Review of an Adverse Benefit Determination.
A Claimant may institute review of an adverse benefit determination within 180
days of the Claimant's receipt of notification of that determination. Such a
review should be initiated in writing, addressed to the Fund office.
(3) The following procedures shall apply to any review sought by a
Claimant concerning an adverse benefit determination under this Plan:
(a) The Claimant shall have the opportunity to submit written
comments, documents, records and other information relating to the claim for
benefits.
(b) The Claimant shall be provided, upon request and free of charge,
reasonable access to, and copies of, all documents, records and other
information relevant to the Claimant's claim for benefits. Whether a document,
record or other information is relevant to a claim shall be governed by the
following: The document shall be "relevant" if it was relied upon in making the
benefit determination, submitted, considered or generated in the course of
making the benefit determination, without regard to whether such document,
record or other information was relied upon in making the benefit determination
or demonstrates compliance with the administrative process and safeguards
required herein or by applicable law.
(c) The review of the adverse benefit determination shall take into
account all comments, documents, records and other information submitted by the
Claimant relating to the claim, without regard to whether such information was
submitted or considered in the initial benefit determination.
(d) Review of the adverse benefit determination shall be give deference
to the adverse benefit determination and will be conducted by an appropriate
fiduciary of the Plan who is neither the individual who made the adverse benefit
determination that is subject to the appeal nor the subordinate of any such
individual.
(e) If the adverse benefit determination was based in whole or in part
on a medical judgment, including determinations with regard to whether a
particular treatment, drug or other item is experimental, investigational or not
medially necessary or appropriate, then the appropriate Plan fiduciary shall
consult with a health care professional who has the appropriate training and
experience in the relevant field.
(f) The review process shall identify the medical or vocational expert,
if any, whose advise was obtained on behalf of the Plan in connection with the
Claimant's adverse benefit determination, without regard to whether the advice
was relied upon in making the benefit determination.
(g) If a health care professional was consulted in connection with the
adverse benefit determination, that person shall not be consulted in connection
with the review of the adverse benefit determination.
(h) In the case of a claim involving urgent care, there shall be
provided an expedited review process pursuant to which a request for an
expedited appeal of an adverse benefit determination may be submitted orally or
in writing by the Claimant, and all necessary information, including the Plan's
adverse benefit determination on review, shall be transmitted between the Plan
or IBC and the Claimant or Claimant's authorized representative by telephone,
facsimile or other available similarly expeditious methods.
(4) Right to Hearing Before Trustees' Appeals Committee. The
Trustees' Appeal Committee will consist of two (2) Trustees designated by the
Plan's Board of Trustees. A Claimant or Claimant's authorized representative
may appear before this committee to present any evidence or argument in support
of the claim review.
(5) Content of Claim Review Determination. Each claim review
determination shall be signed by at least two (2) Trustees authorized by the
full Board of Trustees to resolve such claim review. The content of each
determination will include: the specific reason or reasons for the adverse
benefit determination; reference to the specific Plan provision on which the
adverse benefit determination is based; and a statement that the Claimant is
entitled to receive, upon request and free of charge, reasonable access to, and
copies of, all documents, records and other information relevant to the
Claimant's claim for benefits. Whether a document, record or other information
is relevant to a claim for benefits shall be determined by Paragraph g(3)(b) of
this section.
(6) Time Frames for Claim Review Determination. The following
time frames shall apply to any rulings upon a requested claim review:
(a) Urgent Care Claims. In the case of a claim involving urgent
care, the Plan shall notify the Claimant, in accordance with Paragraph e of this
section, of the Plan's benefit determination on review as soon as possible,
taking into account the medical exigencies, but not later than 72 hours after
receipt of the Claimant's request for review of an adverse benefit determination
by the Plan.
(b) Pre-Service Claims. In the case of a pre-service claim, the
Plan shall notify the Claimant in accordance with Paragraph e of this section,
of the Plan's benefit determination on review within a reasonable period of time
appropriate to the medical circumstances. Such notification shall be provided
not later than 30 days after receipt by the Plan of the Claimant's request for
review of the adverse benefit determination period.
(c) Post-Service Claims. In the case of a post-service claim,
the ruling on the claim review shall not be made later than the date of the
Trustees' Meeting that immediately follows the Plan's receipt of the request for
review, unless the request for review was filed within 30 days preceding the
date of such Meeting. In such a case, a benefit determination may be made no
later than the date of the second Trustees' Meeting following the Plan's receipt
of the request for review. If special circumstances (such as the need to hold a
hearing) require a further extension for processing, a benefit determination
shall be rendered not later than the third Trustees' Meeting following the
Plan's receipt of the claim review. If such an extension of time for review is
required because of special circumstances, the Plan shall notify the Claimant in
writing of the extension, describing the special circumstances and the date by
which the benefit determination will be made, prior to the commencement of the
extension. The Plan shall notify the Claimant, in accordance with Paragraph e
of this section, of the benefit determination as soon as possible, but not later
than 5 days after the benefit determination is made.
(d) Disability Claims. In the case of a claim for disability
benefits under this Plan, a ruling on the claim review shall be made not later
than the date of the Meeting of the Trustees that immediately follows the Plan's
receipt of the claim review, unless the claim review is filed within 30 days
preceding the date of such Meeting. In such case, a benefit determination may
be made by not later than the date of the second Meeting following the Plan's
receipt of the request for review. If the special circumstances (such as the
need to hold a hearing) require a further extension of time for processing, a
benefit determination shall be rendered not later than the third Meeting of the
Trustees following the Plan's receipt of the request for review. If such an
extension of time for a review is required because of special circumstances,
the Plan shall notify the Claimant, in writing, of the extension, describing the
special circumstances and the date by which the benefit determination shall be
made prior to commencement of the extension period. The Plan shall notify the
Claimant, in accordance with Paragraph e
of this section, of the benefit determination, as soon as possible, but not
later than 5 days after the benefit determination is made.
(7) Furnishing Documents. In the case of an adverse benefit
determination on review, the Plan shall provide such access to, and copies of,
documents, records and other information as appropriate and required by law.
(8) Definitions. The following definitions shall apply herein:
(a) A claim involving "urgent care" means any claim for medical care or
treatment with respect to which the application of the time period for making
non-urgent care determinations could seriously jeopardize the life or health of
the Claimant or the ability of the Claimant to regain maximum function or, in
the opinion of a physician with knowledge of the Claimant's medical condition,
would subject the Claimant to severe paid that cannot be adequately managed
without the care or treatment that is the subject of the claim.
(b) "Pre-service claim" means any claim in which receipt of the benefit
is conditioned, in whole or in part, upon precertification or preauthorization
by the Plan.
(c) The term "post-service claim" means any claim that is not a
pre-service claim.
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