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Skip Navigation LinksHome » Health Benefit Info Active » Medical  
 

The Plan provides coverage for covered medical expenses as specified in the SPD booklet and in the applicable Schedule of Benefits incurred as a result of a non-occupational illness or injury.

Comprehensive Medical Benefits
The Plan offers covered individuals comprehensive medical benefits including coverage for many hospital & physician services, in network surgi-centers,  diagnostic x-ray, imaging and lab tests, durable medical equipment, emergency room physician services, skilled nursing, home health, hearing aids, maternity benefits, behavioral health, substance use disorder and organ transplants.  

Save Money - Use A PPO Provider
When you use a PPO provider, you will receive a higher level of benefits.  The Plan pays as follows:  

BCBS PPO Provider
80% paid by Plan
20% paid by you
Non PPO Provider
60% paid by Plan
40% paid by you

Most comprehensive hospital and professional benefits are subject to the calendar year deductibles and out–of-pocket maximums. PPO and non-PPO deductibles and out-of-pockets maximums are separate and cannot be combined. The Plan does not pay for expenses above reasonable and customary charges for non-PPO providers. 

In certain circumstances, the Plan provides coverage for physical, occupational speech and developmental therapies.
 
The Plan also provides coverage for certain preventative care, such as immunizations and colorectal screening, mammograms and more.
 
Preferred Provider Organization
PPO vs Non PPO: Knowing the Difference Saves you Money

The Plan offers access to a Preferred Provider Organization (PPO) through BCBS of Illinois. When you or your eligible dependents use a PPO provider physician and/or hospital, you save money both for your family and the Plan. BCBSIL has contracts with providers that participate in their network (PPO) to accept a negotiated dollar amount. Doing so saves you money in two ways: 1) The overall cost of the service is lower as a result of negotiated discounts and 2) the Plan typically pays a higher percentage of the covered expenses.

If a PPO provider refers you to a hospital or facility, be sure to ask if it is in the BCBS of Illinois PPO network. As the chart below shows, using healthcare providers in the PPO network you can maximize your medical benefits and save money for yourself and the Fund.
 

Example of Network Savings:

John Smith has a knee replacement surgery on January 5, 2014.

  In-Network BCBS Provider Out-of-Network Provider
Cost of single knee replacement $70,000 $70,000
Network Discount ($30,000) n/a
Total charges for consideration $40,000     $54,000***
Participant Pays *
(Deductible, Coinsurance)**
$2,300     $22,600***
Plan Pays $37,700 $47,400

 *     In this example, all covered in-network benefits for the remainder of the 2014 calendar year will be paid at 100% as John's deductible and his Annual Co-Insurance Maximum have been met. 

 **    In-network and out-of-network deductible and coinsurance limits are separate.

 *** The amounts charged for covered out-of-network medical expenses are subject to the Reasonable and Customary Allowances as adopted by the Fund. Amounts over the Reasonable and Customary Allowance ($16,000), plus deductible ($600) and coinsurance ($6,000) are the covered individual's responsibility.

To Find a BCBS PPO Provider
To see if a Physician or Hospital is a PPO provider contact BlueCross BlueShield of Illinois at 1-800-810-2583 or visit their website at www.bcbsil.com.
 
Calendar Year Deductible
The calendar year deductible is the amount of covered medical expenses a participant or covered individual pays each calendar year before benefits become payable by the Plan with respect to Comprehensive Medical Benefits. The deductible applies to both hospital and physician expenses.
 
The calendar year deductible applies only once in any calendar year, even though a covered individual may have multiple injuries or illnesses during the year.

 
In-Network                   PPO Provider
Out-of-Network
Non-PPO Provider*    
Calendar Year Deductible
$300/Individual
$600/Individual or
$900/Family (3 or more)
$1800/Family (3 or more)
PPO and non-PPO deductibles are separate and CANNOT be combined to reach maximums.

 
Deductible Carryover
All covered medical expenses incurred in the last three (3) months of a calendar year (October, November and December) applied toward the PPO or non-PPO calendar year deductible may also be applied to the calendar year deductibles for the next calendar year.
 
Coinsurance and Co-Payments
The coinsurance amount is the participant’s or covered individuals share of the cost of covered services or covered supplies expressed as a percentage. Coinsurance amounts are only applicable to expenses covered by the Plan. Each year, you must satisfy the calendar year deductible (either individual or family maximum). The Plan generally pays a percentage of the covered medical expenses and you pay the rest up to the out-of-pocket maximum as follows:
 


PPO Provider

Non-PPO Provider*
Covered Medical Expenses
80% paid by Plan
20% paid by you
60% paid by Plan
40% paid by you
*For Non-PPO Providers the Plan pays on reasonable and customary charges, which are based on other similar services incurred in the same geographical area. Amounts over the reasonable and customary allowance are the covered individual's responsibility.
 
PPO and non-PPO deductibles and out-of-pocket maximums are separate and CANNOT be combined to reach maximums.
 
A co-payment (also called co-pay) is a flat dollar amount. For example, when you go to the emergency room or a pharmacy, you pay a co-payment and the Plan pays the remaining covered expenses in accordance with Plan provisions.
 
Out-of-Pocket Maximum
The Plan limits the amount you pay out-of-pocket in a calendar year under your Comprehensive Medical benefits for both physician and hospital expenses. After you satisfy the calendar year deductible (either individual or family maximum) and the maximum coinsurance amounts, the Plan pays 100% of any additional PPO discounted or Non-PPO reasonable and customary covered medical expenses for the remainder of the calendar year.
 
 

PPO Provider

Non-PPO Provider
Hospital & Physician Expenses
$2,000 per Individual
$6,000 Family Maximum
(3 or more)
$6,000 per Individual
$18,000 Family Maximum
(3 or more)
PPO and non-PPO out-of-pocket expenses are separate and CANNOT be combined to reach maximums.
 
Hospital Benefits
The Plan pays up to 180 days of hospital confinement per eligible participant or covered individual each calendar year.
 
Outpatient Hospital Care
The Plan covers medically necessary treatment in connection with outpatient surgery, outpatient diagnostic x-ray and laboratory for a non-occupational (not work related) illness, injury or accident as described below. Outpatient cobalt and deep x-ray treatment and chemotherapy are covered whether or not initial treatment was given as an inpatient.
 
Outpatient Surgi-Center Care
The Plan covers your medically necessary outpatient surgical facility fees for non-occupational (not work-related) illnesses, injuries or accidents when prescribed by a physician. This benefit is available as long as you or your dependent is eligible for benefits under the Plan when services or supplies are rendered.
 
When you use a PPO in-network provider, you will receive a higher level of benefits. The Plan pays as follows:
 
BCBS PPO In-Network Hospital
80% Coverage (subject to a Calendar Year Deductible)
BCBS PPO In-Network Surgi Center
80% Coverage (subject to a Calendar Year Deductible)
Non-PPO Hospital
60% Coverage (subject a to Calendar Year Deductible)
Surgi Center Facility not affiliated with the BCBS PPO network or a Hospital (i.e., Free Standing)
NO COVERAGE (zero payment)
 
CLAIMS AND APPEALS

This section describes the procedures for filing claims for benefits from the Plan. It also describes the procedures for you to follow if your claim is denied in whole or in part and you wish to appeal the decision to a Claims Fiduciary.

How and When to File Claims

Generally, when you use the Plan’s contracted providers, the provider will file the claim on your behalf.  Claim forms for out-of-network benefits can be obtained from the contracted provider and filed with the appropriate provider.  You must file a claim for benefits within 24 months from the date of service. When a claim is submitted, the Fund Office will determine if you are eligible for benefits and the contracted provider will calculate the amount of any benefits payable.

Claims recognized by the Plan include requests for health care benefits that must include:

  • Patient name and date of birth;
  • Your name and Social Security number or other ID number assigned by the Fund;
  • Date of service or date of fill or refill for prescription drug claims;
  • Specific services performed and expenses charged for each service;
  • Type of service defined by a recognized diagnosis code, including individual charges for each;
  • Attending physician’s or provider’s name and federal tax ID number (not required for prescription drug claims);
  • Place of service;
  • Billing address; and
  • Previous balances paid.

Authorized Personal Representative

You may designate an Authorized Personal Representative to act on your behalf by notifying the Health Benefits Department and completing and submitting an Authorized Personal Representative Form.  If an authorized personal representative is designated, correspondence relating to the claim or subsequent appeal may be shared with the designated authorized personal representative, unless otherwise specified.  An individual who holds a health care power of attorney is deemed an authorized representative.

You may obtain an Authorized Personal Representative Form from the link below or by calling the Health Benefits Department at 312-787-9455, menu option 3.

Click here for an Authorized Personal Representative Form.

General Rules Governing Claims 

Covered individuals may submit claims in paper form specified by the designated Claims Fiduciary or their providers may submit claims in paper form or through Electronic Data Interchange (EDI). Claims must be submitted to the Plan’s contracted provider of service, within 24 months of the date of service or other period specified by a third party Claims Fiduciary.  

If a covered individual’s provider and service(s) were obtained outside the contracted provider’s network area, the provider must file the claim with the contracted provider or the local affiliate of the contracted provider, if applicable.

Each claim must indicate the name of the patient, name of the participant, and the participant’s Social Security number or ID number that may be assigned by the Fund Office, the date for each service for which the claim is made, the provider’s name and tax identification number, the appropriate ICD code (diagnosis) and specific services provided, as defined by the appropriate CPT, HCPCS, CDT, or other nationally recognized codes, and the amount charged for each service. 

A covered individual must pay any amounts not paid by the Fund, with the exception of PPO network discounts or discounts that may be negotiated between the Plan and the provider on out-of-network claims. PPO or other negotiated discounts do not apply to expenses that are not covered by the Plan.

A covered individual is prohibited from assigning his rights under the medical portion of the Plan to a third party or in any way alienating the covered individual’s claims for benefits. Any attempt to assign rights or in any way alienate a claim for benefits will be void and will not be recognized by the Fund as an assignment. The Fund will treat any document attempting to assign a participant’s rights, or to alienate a claim for benefits to a provider, as an authorization for direct payment by the Fund to the provider. In the event that the Fund receives a document claiming to be an assignment of benefits, the Fund may send payments for the claims to the provider, but will send all claim documentation, such as an explanation of benefits, and any procedures for appealing a claim denial directly to the covered individual. If the Fund denies the claim, only the participant, the participant’s spouse, the patient or his authorized representative will have the right to appeal. 

The Fund will pay claims only when covered under the terms of the Plan provisions under which a covered individual is eligible. If the Fund pays claims that it is not required to pay, it may recover and collect payments from a covered individual or any other entity or organization to whom the Fund was not required to make the payment or that received an erroneous payment. The Fund may recover such erroneous payments through, but not limited to, an offset or reduction of any future benefits a covered individual, or other eligible dependents, may be entitled to receive from the Fund. The Fund shall be permitted to pursue legal and equitable remedies to recover overpayments.  

For purposes of this section, the Claims Fiduciary means the entity that has full discretionary authority to interpret the terms of the Plan and to decide benefit claims under the Plan and the appeal of such decision, and to maintain any applicable external review process. The Plan’s Claims Fiduciary is the Board of Trustees unless the Trustees take action to delegate such authority to a third party Claims Fiduciary, such as to an insurance carrier or to a third party service provider responsible for maintaining a benefit program under the Plan.  

Please note that the Trustees have designated Claims Fiduciaries for the Plan who have the authority to decide and review all benefit claims and all denied claims upon appeal under the Plan as follows: 

•     Fund Office for medical claims and eligibility.

•     ComPsych, Guidance Resources for mental health and substance use     disorder claims.

•     Delta Dental of Illinois for dental claims.

•     Express Scripts, Inc. for prescription drug claims.

•     Diplomat Specialty Pharmacy for specialty drug claims.

•     EyeMed Vision Care for vision claims.

•     Aetna Life Insurance Company for life insurance and accidental death and dismemberment claims. 

The above Claims Fiduciaries are named fiduciaries under the Active Plan and have the authority to make final decisions regarding claims for benefit consideration under the Plan. 

Types of Claims 

There are several types of health care claims under the Plan, including medical, mental health and substance use disorder, prescription drug, dental, hearing and vision claims. Health care claims include the following: 

•   Urgent Health Care Claim: Any claim for medical care or treatment with respect to which the application of the periods for making pre-service claim determinations would, in the opinion of a physician with knowledge of the covered individual’s condition, seriously jeopardize the covered individual’s life or health or ability to regain maximum function if normal pre-service standards were applied or would subject the covered individual to severe pain that cannot be adequately managed without the care or treatment for which approval is sought;

•   Pre-Service Health Care Claim: Any claim for a benefit for which the Plan requires approval of the benefit (in whole or in part) before the covered individual obtains medical care;

•   Post-Service Health Care Claim: Any claim for health care benefits for which the covered individual has already received the services in the claim; and

•   Concurrent Care Claim: Any claim that is reconsidered after it is initially approved and the reconsideration results in reduced benefits, an extension of benefits or a termination of benefits. 

The deadlines for processing the initial determination and the extension period are shown in the chart on the next page. The Plan may request an extension of the initial determination period due to matters beyond the Fund’s or Claims Fiduciary’s control. 

Type of Claim

Response Time Upon Receipt of Your Claim

Extension

Urgent claims

72 hours

Extension not applicable. However, if additional information is required from you, you will be notified within 24 hours of receipt of the claim the specific information needed, and you have at least 48 hours to provide the information.

Pre-service claims/ Predetermination of Benefits

15 days

You will be notified within the 15-day initial determination period that one 15-day extension is necessary. If an extension is necessary due to incomplete information, you must provide the additional information within 45 days from the date of receipt of the extension notice. If the Health Benefits Department or Claims Fiduciary receives the requested information in the 45-day period, the claim will be processed within 15 days following the receipt of the additional information.

Post-service claims

30 days

You will be notified within the 30-day initial determination period that one 15-day extension is necessary. If the extension is necessary due to incomplete information, you must provide the additional information within 45 days from the date of receipt of the extension notice. If the Health Benefits Department or Claims Fiduciary receives the requested information in the 45-day period, the claim will be processed within 15 days following the receipt of the additional information.

Concurrent

As soon as possible, in time to receive a decision before reduction or termination of the benefit.

Not applicable.

Short Term Disability

45 days

You will be notified within the 45-day initial determination period that up to an additional 60 days maximum is necessary. However, if a determination is not made within the first 75 days, you will be notified that an additional 30 days is necessary.

Life and AD&D Insurance

90 days

You will be notified within the 90-day initial determination period of the information needed. The 90-day extension of initial determination period listed above includes any time needed by the Claims Fiduciary to obtain this information.

Claim Denial 

If for any reason your claim is denied, in whole or in part, you will receive a written notice comprising the information detailed below.  

When the Plan or Claims Fiduciary notifies you of its initial denial of your claim, it will provide (if relevant): 

•   Identification of the claim involved, including date of service, provider, claim amount and, a statement with denial codes and their respective meanings;

•   The specific reason or reasons for the decision, and any Plan standards used in denying the claim;

•   Upon request, free of charge, the diagnosis code and its corresponding meaning, as well as the treatment code and its corresponding meaning;

•   Reference to the Plan provisions on which the decision was based;

•   A description of any additional information or material needed to properly process your claim and an explanation of the reason it is needed;

•   A copy of the Plan’s internal review procedures and time periods and information needed to appeal your claim, and external review processes for health care claims;

•   A statement of your right to bring a civil action under ERISA following an adverse benefit determination of your claim on review; and

•   Disclosure of the availability of, and contact information for, any applicable ombudsman established under the Affordable Care Act to assist individuals with the internal claims and appeals and external review processes for health care claims. 

In addition, for health care and disability claims, the notice will include: 

•   A copy of any internal rule, guideline, protocol or similar criteria that was relied on in making the decision to deny your claim, or a statement that a copy is available to you, free of charge, upon request; and

•   A copy of the scientific or clinical judgment, or statement that it is available to you, free of charge, upon request, if your claim is denied due to medical necessity, experimental or investigational treatment, or similar exclusion or limit. 

NOTE: The applicable Claims Fiduciary decides and processes all levels of an appeal for a benefit claim. 

Adverse Benefit Determination Appeal Process 

You may appeal any denied post-service or urgent care health claims. The Explanation of Benefits (EOB) that you receive serves as the notice of an adverse benefit determination when payment of a claim for benefits has been denied by a Claims Fiduciary, in whole or in part, for the reasons stated on the EOB. An adverse benefit determination also includes a rescission of coverage, whether or not there is an adverse effect on any particular benefit at that time. A rescission of coverage, as described more fully on page 87, is a cancellation or discontinuance of coverage that has retroactive effect, except to the extent it is attributable to a failure to timely pay required premiums or contributions or other events (such as fraud). 

You may appeal a denied post-service claim for health care or Short Term Disability benefits within 180 days after receiving notice of the denied claim. For a claim for life insurance or accidental death and dismemberment benefits that has been denied, in whole or in part, you may file the appeal within 90 days after receiving notice of the denied claim. All appeals must be in writing on the forms required by the applicable Claims Fiduciary and addressed to the applicable Claims Fiduciary, and must include your or your authorized personal representative’s signature. Your appeal should include evidence or specific facts and Plan provisions that support your claim. Submit a completed appeal form and any additional information to substantiate the appeal to the applicable Claims Fiduciary. Forms for appealing denied health care or Short Term Disability claims may be found in the Forms link.  Look for Appeal Form (Welfare). 

You have certain rights when you appeal a claim: 

•   To receive, upon written request, copies of all documents relevant to the claim;

•   To designate an authorized personal representative (who may be an attorney);

•   To request, free of charge, a copy of relevant information if your claim is denied based on internal rules, guidelines, protocol or other similar criteria;

•   To request, free of charge, a copy of an explanation of the scientific or clinical judgment that is the basis of the adverse benefit determination for a health care claim or Short Term Disability claim, if your claim is denied based on medical necessity, experimental treatment or similar exclusion or limit; and

•   To be advised of the identity of any medical expert relied upon for the determination of the health care claim or Short Term Disability claim. 

For health care claims, the Plan will also provide you, free of charge, with any new or additional evidence considered or rationale relied upon or generated by the Claims Fiduciary (or at the direction of the Claims Fiduciary) in connection with the claim. 

Appeal Review 

For post-service health care claims, Short Term Disability claims and eligibility claims for which the Board of Trustees is the Claims Fiduciary, the Health Benefits Department will review your appeal within five business days of receiving it to determine if it is in order. Appeals will be reviewed at the next regularly scheduled appeals meeting of the Trustees, who meet at least quarterly.  

However, if the request for review is received within 30 days of the next regular meeting, the request for review will be considered at the second regularly scheduled meeting following receipt of the request. If special circumstances require a further extension for processing, a determination will be made at the third regularly scheduled meeting following receipt of the request for review. Before the extension begins, you will be advised in writing in advance if this extension will be necessary, and will be notified of the special circumstances and the date by which a determination will be made.  

Once a decision has been made by the Trustees, their decision will be mailed to you within five business days after making a determination. If your appeal is denied, you may have the right to request an external review from an Independent Review Organization (IRO) within four months of the date of the adverse benefit determination or denial letter. If your appeal is denied, you also have the right to initiate a lawsuit under ERISA Section 502(a). Any lawsuit must be initiated within 12 months of the denial on review.    

When the Claims Fiduciary notifies you of its determination on your appeal, it will provide: 

•   For a health care claim, identification of the claim involved, including date of service, provider, claim amount and a statement with denial codes and their respective meanings;

•   The specific reason or reasons for the decision, and any Plan standards used in denying the claim;

•   Reference to the Plan provisions on which the decision was based;

•   A statement that you may request, without charge, the diagnosis code and its corresponding meaning, as well as the treatment code and its corresponding meaning;

•   A statement notifying you that you have the right to request a free copy of all documents, records and other information relevant to your claim;

•   Information relating to external review processes for health care claims, and any voluntary appeal procedures offered by the Plan;

•   A statement of your right to bring a civil action under ERISA; and

•   Disclosure of the availability of, and contact information for, any applicable ombudsman established under the Affordable Care Act to assist individuals with the internal claims and appeals and external review processes for health care claims. 

Questions? Contact the Health Benefits Department Monday–Friday from 8:00 a.m. to 4:30 p.m. (CT) at 312-787-9455, menu option 3.

In addition, for health care and Short Term Disability claims, the notice will include: 

•   A copy of any internal rule, guideline, protocol or similar criteria that was relied on in making the decision to deny your claim, or a statement that a copy is available to you, free of charge, upon request; and

•   A copy of the scientific or clinical judgment, or statement that it is available to you, free of charge, upon request, if your claim is denied due to medical necessity, experimental or investigational treatment, or similar exclusion or limit. 

For post-service health care claims for which a third party is the Claims Fiduciary, the designated Claims Fiduciary will review the claims appeal and provide its written decision to the covered individual within 60 days of receiving the appeal. The covered individual will receive written notice of the decision within 30 days after the appeal was received when the Claims Fiduciary has two levels of appeal. 

For life insurance and accidental death and dismemberment claims, the Claims Fiduciary (insurer) will review the claims appeal and provide its written decision within 60 days of receiving the appeal. In some instances, the covered individual will be notified in the original 60-day period that an extension is required and that the Claims Fiduciary will provide a written decision no later than 120 days after receiving the appeal. 

External Review of Claims 

If an appealed health care claim is denied by the Appeals Committee of the Board of Trustees or a third party Claims Fiduciary, you may request further review by an Independent Review Organization (IRO), as described below. Only denied health care claims that involve medical judgment and rescission claims are eligible for external review. Claims that do not involve medical judgment (e.g., eligibility claims), dental claims and vision claims are not eligible for external review. Generally, you may only request an external review after you or your authorized personal representative have exhausted the internal review and appeals process described above. The external review of claims is intended to comply with applicable law and regulations and guidance as issued by the Department of Labor, Department of Health and Human Services and the Internal Revenue Service. 

External Review of Standard Claims. External review of a claim will only apply to an adverse benefit determination or final internal adverse benefit determination involving a medical judgment. You must request external review of a non-urgent claim in writing, within four months of the date the EOB indicates an adverse benefit determination or the date of the letter advising of an adverse appeal claim benefit determination, whichever is later. 

Expedited External Review of Claims. You may request an expedited external review if you receive an initial adverse benefit determination that involves a medical condition for which the timeframe for completion of an internal appeal or standard external review would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function, and you have filed a request for an urgent care internal

appeal or you receive an adverse appeal benefit determination that concerns an admission, availability of care, continued stay or health care item or service for which you received emergency services, but have not yet been discharged from a facility. 

Preliminary Review. The Claims Fiduciary will complete a preliminary review of the request immediately upon receipt of your request for an expedited external review or within five business days of the Claims Fiduciary’s receipt of your request for an external review to ensure the claim is in order. The Claims Fiduciary will notify you in writing within one business day of completing its preliminary review if your request meets the requirements for external review. If applicable, the notification will inform you if the request is complete but not eligible for external review, in which case the notice will include the reasons for its ineligibility and the contact information for the Employee Benefits Security Administration (toll free number 866-444-EBSA [3272]).  

If the request is not complete, the notice will describe the information or materials needed to make the request complete and allow you to complete your request for external review within the four-month filing period or within a 48-hour period following receipt of the notification, whichever is later. 

Review by Independent Review Organization (IRO) 

If the request is complete and eligible, the Claims Fiduciary will assign the request to an IRO. The IRO is not eligible for any financial incentive or payment based on the likelihood that the IRO would support the denial of benefits. The Claims Fiduciary may rotate assignment among IROs with which it contracts. Once the claim is assigned to an IRO, the following procedure will apply: 

•   The assigned IRO will notify you in writing of the request’s eligibility and acceptance for external review, including directions about how you may submit additional information regarding your claim (generally, you must submit such information within 10 business days following your receipt of notice from the IRO). 

•   If you submit additional information related to the claim, the assigned IRO will, within one business day, forward that information to the Claims Fiduciary. Upon receipt of any such information, the Claims Fiduciary may reconsider its adverse benefit determination that is the subject of the external review. Reconsideration by the Claims Fiduciary will not delay the external review. If the Claims Fiduciary reconsiders the claim and reverses its adverse benefit determination, it will provide written notice of its decision to you and the IRO within one business day after making that decision and the IRO will terminate its external review. 

•   The IRO will review all timely received information and documents without regard to whether the information was submitted or considered in the initial benefit determination. 

•   After the IRO receives the request for the external review, the assigned IRO will provide written notice of its final external review decision to you and the Claims Fiduciary within 45 days. The assigned IRO’s decision notice will contain: 

   A general description of the reason for the request for external review, including information sufficient to identify the claim (including the date or dates of service, the health care provider, the claim amount (if applicable), the diagnosis code and its corresponding meaning, the treatment code and its corresponding meaning and the reason for the previous denial); 

   The date that the IRO received the assignment to conduct the external review and the date of the IRO decision;  

 

   The principal reason(s) for its decision, including references to the evidence or documentation and specific coverage provisions and evidence-based standards considered in reaching its decision; 

   A statement that the determination is binding except to the extent that other remedies may be available to you or the Fund under applicable state or federal law; 

   A statement that judicial review may be available to you; and 

   Current contact information, including phone number, for the health insurance consumer assistance or ombudsman established under law to assist with external review processes. 

Expedited Review by Independent Review Organization 

If you have met the requirements for an expedited review in accordance with the criteria described on page 63, the IRO will provide notice of the final external review decision, in accordance with the requirements in this section, as quickly as your medical condition or circumstances require, 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, within 48 hours after the date of providing that notice, the IRO must provide written confirmation of the decision to you and the Claims Fiduciary. 

For more information, contact the Health Benefits Department at the Fund Office, Monday–Friday from 8:00 a.m. to 4:30 p.m. (CT) at 312-787-9455, menu option 3.

After External Review 

If the final external review reverses the Claims Fiduciary’s adverse benefit determination, upon the Claims Fiduciary’s receipt of notice of such reversal, the Plan will immediately provide coverage or payment for the reviewed claim. 

If the final external review upholds the Claims Fiduciary’s adverse benefit determination, the Plan will maintain denial for the reviewed claim. If you are dissatisfied with the external review determination, you may seek judicial review as permitted under ERISA Section 502(a). Any lawsuit must be initiated within 12 months of the denial on appeal. 

The Trustees, the Appeals Committee or the Claims Fiduciaries designated by the Trustees have sole, full and discretionary authority to make final determinations regarding any application for benefits, the interpretation of the Plan and all documents, rules, procedures and terms of the Plan, and any administrative rules adopted by the Claims Fiduciaries. It is the intention that the decisions of the Trustees or Claims Fiduciaries will be accorded judicial deference in any subsequent administrative or court proceeding, to the extent the decisions do not constitute an abuse of discretion. Benefits will only be paid under the Plan if the Trustees or their delegated Claims Fiduciaries decide, in their discretion, that the Claimant is entitled to them. 

Exhaustion of Remedies 

Generally, you must follow and completely exhaust the Plan’s appeal procedures (including time limits) before you can file a lawsuit under ERISA or initiate proceedings before any administrative agency. If the Plan fails to adhere to all claims and claims appeal requirements, you are deemed to have exhausted the claims appeal process and may seek an external review or file a lawsuit, unless the Plan’s failure is minor. In the event you submit a claim for review and the claim is denied, any legal action must begin within 12 months of the date the Fund provides an adverse benefit appeal determination. 

Facility of Claims Payment 

In the event the Fund becomes aware that you have been deemed incompetent or incapable of executing a valid receipt and no guardian has been appointed, the Fund may pay any amount otherwise payable to you to your spouse or any other person or institution determined by the Fund to be equitably entitled to payment. Any payment in accordance with this provision discharges the Fund from any further obligation. 

Right to Information in Claims and Appeals Process 

You have the right to receive, upon written request, copies of all documents relevant to the decision made on your appeal. You may also request in writing to receive the identification of medical or other experts whose advice was obtained for reviewing your appeal. Any and all disclosures will be made in accordance with Health Insurance Portability and Accountability Act of 1996 (HIPAA).

 

 

 

 

 

 
 

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